e-Homeopathy - Minor Illness or Injury consultation form
e-Homeopathy consultations are suitable for: INJURIES or MINOR ILLNESSES that you've had for no longer than 14 days.

Anything recurrent or longstanding requires a full consultation in person or by Skype as there’s more that should be taken into account.

You will get an email within 48 hours with a homeopathic remedy prescription, directions on taking your remedy and details of where to obtain it. If necessary we will get in touch first to clarify your symptoms. Fees are £15 and include follow up emails for up to a week if needed.

Please PROVIDE AS MUCH DETAIL AS POSSIBLE when answering the questions.
What minor illness or injury would you like help with today? *
Your answer
Current Complaint
When did this begin?
Your answer
Do you have any thoughts on what may have triggered it?
(Triggers can be physical or emotional, and are not always obvious, so please mention anything different that happened around the time the complaint began. For example: exposure to cold wind; getting wet feet; emotional shock; eating too much rich food; grief; anger; an injury; bad news; medication or vaccination).
Your answer
Did symptoms come on suddenly or gradually?
Your answer
Where exactly is the problem?
Does it change location? Which side - or both?
Your answer
Can you describe the pain or other sensation?
(This is very subjective, but describing what it feels similar to can be helpful)
Your answer
Where is the pain and does it spread or extend to anywhere else? What makes this happen?
Your answer
Do you have any discharges?
(e.g. mucus, vomiting, diarrhoea). Appearance, colour, odour, consistency, quantity? Quality (e.g. bland, burning)?
Your answer
Coughs only: Please describe the cough as best you can.
Sound (e.g. barking; hard; rattling)? Pattern (e.g. Infrequent but long fits of coughing; single coughs)? What seems to bring on coughing (e.g. drinking; going outside; falling asleep)? Wet or dry cough - and does the time of day make a difference to that?
Your answer
Do any other new symptoms accompany the complaint?
(Not a separate complaint, but symptoms that accompany the original complaint, e.g.: pain in the forehead when you cough; aching thighs with menstrual cramps; crying with nausea). This includes digestive or urinary symptoms.
Your answer
General changes
When treating a minor illness or injury we look for any changes to how you usually are. So if you are usually thirsty, and are still thirsty, we don’t need this information. But if you normally hardly drink anything, and are suddenly gulping down pints of ice cold water - then we need to know that. And as with the section above, the things that are most individual to you are the most useful.
Thirst changes:
Drinking how much? What? How often? Sipping or gulping?
Your answer
Food changes:
Strong cravings for anything? Or aversions to anything? Foods making you ill? Changes to appetite?
Your answer
Temperature changes:
Changes to how hot or cold you feel in yourself? Environment you feel best in such as warm room or fresh air? Affected by application of cold or heat? Wanting to be uncovered or wrapped up? If so any particular part of the body? Anything affect this?
Your answer
Perspiration changes:
Sweating more or less? Where on the body/head? Times of day or night? Anything else affecting that?
Your answer
Mood changes:
Wanting company or to be alone? Irritable? Weepy? Any fears - of what? Any other emotional changes?
Your answer
Sleep changes:
Changes to sleep? Or to the position you sleep in? Any strong new dreams? Grinding teeth?
Your answer
Energy level changes:
When (as exactly as possible) do you have most or least energy? Does anything affect this?
Your answer
Appearance changes:
Are you - or the part affected - redder, paler, blue-tinged etc.? If specific areas discoloured please give details.
Your answer
What makes you feel better or worse? *
(This is essential information, and the more individual this is to you the better. Mention especially anything that seems either very important to you or a bit strange. Examples might include better for: fresh air; pressure being applied; warm drinks; consolation; a warm bed; sitting up. Or being worse for: fatty food; draughts; being alone, talking; getting angry; being told off.)
Your answer
What time are your symptoms or you in general worse? *
Be as specific as you can (e.g. '3-5pm' rather than 'afternoon', if appropriate).
Your answer
Anything else you think I should know?
Include anything you haven’t mentioned above, that relates to this acute complaint. Especially anything you might have told me in person by saying “you’ll probably think this is really weird but...” or “I can’t see how this could be related but...” or “my partner/daughter/dad thought I should mention...”.
Your answer
Have you used homeopathy before?
If so then please tell me any remedies you responded well to in the past, and also any potencies you've responded particularly well or badly to.
Your answer
Do you currently have access to a Helios or Ainsworth homeopathy kit?
If so then please tell me which one.
Your answer
Have you received any medication, treatment or medical advice for this complaint? *
If yes, then please give details.
Your answer
Personal Details
Patient's name *
Your answer
Your name
If you are not patient please provide your name and your relationship to patient. Obtain patient’s permission if you are not his/her legal guardian before completing this form
Your answer
Patient's date of birth *
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Patient's GP practice *
Your answer
Patient's address *
Your answer
Confirm email address *
Your answer
Your email address *
If hotmail please also provide an alternative as hotmail is experiencing problems
Your answer
Your phone number
Your answer
Confirm you have read and are aware of e-Homeopathy Minor Illness and Injury Consultation Terms and Conditions: *
Required
Confirm you have read and are aware of the warning signs of serious illness *
e-homeopathy consultations are not a substitute for medical advice. Please call 111 or 999 if you believe it may be a medical emergency.
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