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School of Homeopathyand Research Center

Clinical symptom intake

Symptom intake form

This form follows the structure your consultant uses: the location and sensation of your complaint, its modalities (what makes it better or worse), what accompanies it, and your general symptoms. It takes 15 to 25 minutes. Answer what you can; anything you skip we will cover at your consultation.

1. About you

If you are completing this for a child, enter the child's details and tick the box below.

Do you have a preference between classical and combination homeopathy?
2. Main complaint

Location and sensation: where the complaint is, where it spreads, and exactly how it feels.

Location and extension

Sensation

How does it feel? Choose all that fit
If there is a cough, mucus or discharge, what is it like? Optional
3. Modalities

What makes your complaint better or worse? These details are among the most useful in choosing a remedy.

Better from (amelioration)
Worse from (aggravation)

Concomitants

What else happens at the same time as the complaint?
4. General symptoms

How you are as a whole person: temperature, weather, food, thirst and sleep.

In general, are you
Weather or environment that affects you
Foods or drinks you crave
Foods or drinks you dislike or avoid
Thirst
When you drink, do you take
How often?

Sleep

How do you sleep?
5. Mind and history

How you tend to feel and react, and your medical background.

Which words describe your usual temperament?

History

6. Conditions and consent

Tick any long-standing conditions you would like support with, then confirm and submit.

Respiratory and allergy
Skin
Digestive
Head and nerves
Women's health
Joints and muscles
Hormones and metabolism
Mind and sleep
Children

California disclosure

MIHI's consultants are not licensed physicians. Our services are alternative or complementary to the healing arts services licensed by the State of California, and are not licensed by the State of California. We do not diagnose, prescribe drugs or advise stopping prescribed treatment.