Health Through Nature

Homeopathic Intake Questionnaire

Please answer the following questions that fit your general nature. They may seem
irrelevant to your immediate health concerns however they are important to determine
your overall health picture. Please answer according to your current state. The doctor
will review this document with you to give room for further explanation of choices.
Key:
N = Never !

F = Frequently ! !

B = Better!

W = Worse !

WEATHER
These weather conditions affect me negatively
Clouds
Sun
Damp
Dry
Storms
Wind

S = Sometimes

Fog

None

The change of weather affects me

Strongly agree Slightly agree Neutral Slightly disagree Strongly disagree
I feel better in the following climates
Mountains Seashore Dry Wet Sunny

Cloudy

None Applicable

I am affected by seasons (circle all that apply) Yes No

(B/W) Spring
(B/W) Summer
(B/W) Fall
(B/W) Winter
ENVIRONMENT
I am affected by these sensations
Bright lights Warm rooms Open air Loud Noises

Drafts

Strong odors

I am a ______ natured person

Warm Cold Neither
I tend to become uncomfortable faster in a room that is (circle all that apply)
Warmer than usual (80 degrees)!
Cooler than usual (60 degrees)
In general, I tend to perspire (circle all that apply)
Never Only with exertion When heated When cold

When nervous

Easily

The part of my body where I tend to perspire the most is ___________________

TIME OF DAY
My worst time of the day is (mood, energy, symptoms, etc.) ___________________
My Best time of the day is (mood, energy, symptoms, etc.) ____________________

www.healthTnature.com
1

Health Through Nature

Homeopathic Intake Questionnaire

SLEEP
During sleep I can experience these symptoms (circle all that apply)
Teeth Grinding!
Restlessness!!
Talking
Perspiration! !
Laughing!
!
Frequent Urination
Snoring!
!
Nightmares! !
Recurrent Dreams! !
!
!
Excess Heat or Cold-Where? ___________
My preference for sleep is
Without covers!
Partially covered! Fully Covered (including head)
With window open! Without Clothing! Fully Covered (Not including head)
With air blowing!
Arms or legs out of covers!
My usual sleep position is
Right Side!
Left Side!
On Back!

On Abdomen

FOOD PREFERENCES
I frequently crave the following flavors (circle all that apply)
Sweet!Pungent!
Sour! Salty ! Bitter! Spicy! Smoked!
Juicy! Refreshing
I strongly dislike these flavors (circle all that apply)
Sweet Pungent!
Sour! Salty ! Bitter! Spicy! Smoked!

Juicy! Refreshing

I frequently crave the following beverages/foods

Alcohol!
Apples!
Bacon!!
Bread!!
Chocolate! Coffee!!
Pastries!
Eggs! !
Fruit ! !
Grains!!
Ham! !
Ice! !
Lemons/Lemonade !!
Liquor!!
Meat! !
Oysters!
Pickles!
Vegetables! Vinegar !

Butter! !
Cheese
Fat! !
Fish! !
Ice cream ! Indigestible things
Milk! !
Nut butters
Other _______________

I completely avoid these foods

Alcohol!
Apples!
Bacon!!
Chocolate! Coffee!!
Pastries!
Fruit ! !
Grains!!
Ham! !
Lemons/Lemonade !!
Liquor!!
Oysters!
Pickles!
Vegetables!

Butter! !
Cheese
Fat! !
Fish! !
Ice cream ! Indigestible things
Milk! !
Nut butters
Other ___________________

Bread!!
Eggs! !
Ice! !
Meat! !
Vinegar !

I prefer my food! warm/cold! neither

I prefer my drinks! warm/cold ! neither
I tend to be thirsty
Almost never Several times per day

Several times per hours

Always

I often have a abnormal taste in my mouth Yes/No

www.healthTnature.com
2

Health Through Nature

Homeopathic Intake Questionnaire

If so, what type

Metallic

Bitter

Foul

Sweet

Other ___________________

MENTAL/EMOTIONAL STATE
I tend to worry about (circle all that apply)
Tasks! Emotions!
Financial Security ! Health!!
Mental Functioning! Morals
Others well being! Religion!
!
Social life! Social position!
The future
Work! !
!
Selfishness! !
I am easily frightened Yes/No
I have strong fears of (circle all that apply)
Animals!
Being alone! !
Death! !
Becoming seriously Ill !
Failure !
Falling!/Heights
Ghosts !
Insanity !
Misfortune!
Crowds !
People!
!
Evil! !
Robbers !
Snakes !
Spiders!
Darkness!
!
Thunderstorms Water!
Contagious disease/germs
Something terrible happening!
I find it difficult to stick to a decision
Strongly disagree Slightly disagree Neutral
!
I change my mind frequently about decisions
Strongly disagree Slightly disagree Neutral

Slightly agree

Strongly agree

Slightly agree

Strongly agree

When I am feeling sad or upset, at the very worst point, I need

To be completely alone
To have someone nearby
To be distracted
To vent about what I am feeling
To have someone talk to me and console me
Regarding any past emotional traumatic events, I feel
Resolved grief!
Dwell on past!
Inconsolable!Remorse!
Other: ________________________________

Guilt

At my worst, the following makes me feel much better (circle all that apply)
Rest! !
Massage/Pressure! Crying!!
Yelling!!
Music! !
Dancing
Company! Being alone! !
Talking!
Quiet! !
Darkness
Sunshine
Eating!
Gentle exercise! Vigorous exercise! Exposure to heat!
Exposure to cold
Anything else that consistently makes you feel better: _______________________
Anything else that consistently makes you feel worse: _______________________
I consider myself (circle all that apply)
Stingy!!
Overly Generous! Thrifty!!
Extravagant!
Slow! !
Messy !
!
Fastidious! Calm! !
Always busy !Shy/timid ! !
Outgoing!
Angry!!
Lazy! !
Guilty !!
!
Stubborn!
Yielding
Quiet!
Trusting!
!
Gullible ! Suspicious!
Honest!
Bossy !!
!
Lack of confidence! !

Hurried/Impatient
Restless!
!
Mild tempered !
Coward Talkative
Overly confident!
Lack of moral sense

www.healthTnature.com
3

Health Through Nature

Homeopathic Intake Questionnaire

Others consider me as (circle all that apply)

Stingy!!
Overly Generous! Thrifty!!
Extravagant!
Slow! !
Messy !
!
Fastidious! Calm! !
Always busy !Shy/timid ! !
Outgoing!
Angry!!
Lazy! !
Guilty !!
!
Stubborn!
Yielding
Quiet!
Trusting!
!
Gullible ! Suspicious!
Honest!
Bossy !!
!
Lack of confidence! !
My feelings with the people closest to me are
Loving!!
Affectionate! !
Indifferent! !

Hurried/Impatient
Restless!
!
Mild tempered !
Coward Talkative
Overly confident!
Lack of moral sense

Resent!

Hatred

(If you have a partner/spouse) My feelings toward spouse/lover

Loving!Affectionate! Dissatisfaction!
Disappointment!
Resentment! Hatred
Feelings toward disease/condition are
Optimistic! Doubtful of recovery!Discouraged!Fearful!
My overall outlook on life is
Love life!
Indifferent! Bored!!
Weary of life! !
Suicidal thoughts !!
Suicidal disposition

Despair of recovery
Desire death!

My general mood is often

Morose!
Sad! Apathy/Indifference!Excitement! Exhilaration
I cry
Never! When grieving!

When sad!

When angry ! When happy !Spontaneously

I am forgetful for the following (circle all that apply)

Dates! Names!
Numbers!
What someone just said!

What I just said!

Words

I often make mistakes with (circle all that apply)

Numbers!
Words (reading)!
Words (speaking)! Words (writing)
I am sensitive to (circle all that apply)
Beauty!
Criticism!
Cruel Stories!!
Frightening things! !
Reprimand! Rudeness! Suffering of others! Being made fun of

Music

How often do you have the following behaviors

Abusive (N/S/F)!
Biting (N/S/F)!
Breaking things (N/S/F)
Contrary (N/S/F)! Cursing (N/S/F)!
Disobedient (N/S/F)
Insulting (N/S/F)! Rage! (N/S/F)!
Rudeness (N/S/F)
Striking others (N/S/F)!
!
!
Striking Self (N/S/F)
!

www.healthTnature.com
4