postal address for large packages if different to above:
E.mail and web
Patient's birthplace, time and date of birth:
Sex:
height:
weight:
pulse rate:
missed beats:
blood pressure:
Marital status:
number of children:
boys:
girls:
Please describe the present symptoms and mention if they were of
a sudden or gradual onset, with the most serious, pain -ful, irritating
or embarrasing ones listed first. Also list brief details of previous
serious illnesses and 1. medical treatments and outcome, including
medication e.g., antibiotics, drugs, HRT, also biopsies, scans, tests,
X-rays, any surgery, transfusions etc., and also 2. any alternatives
such as acupuncture or ayervedic, chinese, chiropractic, herbal, homeopathic,
naturopathic (includes nutrition), osteopathic:
Add details of family history: mother, father, brothers, sisters:
Have you suffered from these illnesses or conditions, tick and give
age, circle mild M, or severe S:
aids/HIV sexually transmitted diseases:
M or S
allergies constipation diarrhoea:
M or S
asthma/emphysema chicken pox cancer/tumours:
M or S
bronchitis coughing diabetes:
M or S
pneumonia german measles diptheria:
M or S
hay fever/sinusitis glandular fever dysentry:
M or S
recurrent colds influenza eczema/psoriasis:
M or S
sore throats jaundice ear problems:
M or S
anemia measles epilepsy/fits:
M or S
blood disorders mumps food intolerances:
M or S
blood pressure high rheumatic fever malaria:
M or S
blood pressure low scarlet fever shingles:
M or S
heart troubles sweats swollen/tender glands:
M or S
insomnia whooping cough tuberculosis:
M or S
other illnesses, e.g., problems of the mind such as depression, delusions,
fear etc., please describe:
If known, please note if there were any reactions to any innoculations/immunisations/vaccinations:
Please indicate, with a tick, if there were or are any of the following
skin conditions noticed by you:
acne:
burning cysts:
dryness:
moles:
ringworm:
rash:
skin-tags:
warts:
veruccas:
List accidents: falls, however slight/injuries/trauma etc., with
dates:
Describe any pregnancies and outcome, also implants e.g. coils etc,
the Pill, DNC's, hysterectomy:
Intake of any alcoholic drinks:
smoking history:
Please give details of present diet and meals normally eaten, including
snacks, drinks, beverages etc:
Occupation/s, redundancy, financial or housing worries, temperament,
relationship, regular exercise program or sport, ethnicity, religious
persuasion or current belief system, if any, and hobby etc :
Please return to Norman P. Ball MARH DHom MRN
ND DO Registered Homeopath and Naturopath at Norwood House, West Ave,
Gosforth, Newcastle upon Tyne. NE3 4ES.
Tel: 0191 284 3985. Web: www.nhs-homeopathy.co.uk
www.nhs-naturopathy.co.uk