On Line Health Assessment Questionnaire
If there is more than one problem, repeat the questions for each.
Please provide your name, date of birth, address and email address
What is rare, strange and peculiar about the symptom/symptoms of your illness?
What are the symptoms of your mental and emotional health?
What word or phrase would you use to describe your mental and emotional states?
Have you ever suffered from anxiety or depression?
Do you regularly experience a particular type of uncontrollable emotion?
What are your concentration and memory like?
Do you have any problems getting to sleep?
Do you wake at night?
Do you have dreams that disturb your sleep?
What would you say is your main health problem?
Do you have a diagnosis from your Doctor?
When did the problem first appear?
Where do the symptoms occur?
Describe the main symptoms.
Does anything make the symptoms worse?
Does anything make the symptoms better?
What treatment, if any have you had for this problem?
Does this problem relate to another health issue?
In what way are they affected by each other?
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This form was created inside of Castel Complementary Medicine.