Strong Words
and
Liskeard Storytelling Cafe

Patient Questionnaire

Name [field id=”field_b321e9f”];&nbsp [field id=”field_dfa3582″]

Telephone: [field id=”field_20fbdfa”]

Mobile: [field id=”field_c992293″]

Email: [field id=”field_71f6906″] .

Address; [field id=”field_2df1e52″]

GP’s Name [field id=”field_b321e9f”]   [field id=”field_e788de0″]

GP’s Address; [field id=”field_4bdb9af”]


Please tell me in as much detail as possible – What is the reasoner consulting me?

[field id=”field_a0553f8″]

When did it start?

[field id=”field_a0fbb54″]

If it is a physical complaint list the things that make it better or worse.(e.g.standing, afternoon, after sleep, hot or cold, pressure etc..

[field id=”field_8ae0a77″]

Please describe anything you feel is associated with the current symtomsthat is unusual, rare and/or peculiar or any other information that might be related.

[field id=”field_c056679″]


Please indicate if you have had any of the following and approximately what age:

Measles: [field id=”field_21d9413″];&nbsp[field id=”field_e4b373a”] Yrs old

Mumps: [field id=”field_13c2f6e”];&nbsp[field id=”field_997f38d”] Yrs old

Chicken Pox: [field id=”field_7fb51ff”];&nbsp[field id=”field_26d39c8″] Yrs old

German Measles: [field id=”field_ee03fb3″];&nbsp [field id=”field_ad4f418″] Yrs old

Scarlet Fever: [field id=”field_9453fbb”];&nbsp [field id=”field_a16cc29″] Yrs old

Glandular Fever: [field id=”field_da49a76″];&nbsp[field id=”field_72879f2″]Yrs old

Rheumatic Fever: [field id=”field_e0e315d”];&nbsp[field id=”field_3832d59″]Yrs old

Tonsillitis: [field id=”field_3db9883″];&nbsp[field id=”field_48d3917″]Yrs old

Diphtheria: [field id=”field_dee660b”];&nbsp[field id=”field_d7294e8″]Yrs old

Recurrent Colds: [field id=”field_a4c2ea6″];&nbsp[field id=”field_98029a0″]Yrs old

Ear Problems: [field id=”field_1fe8c98″];&nbsp[field id=”field_4020a0d”]Yrs old

Whooping Cough: [field id=”field_779e768″];&nbsp[field id=”field_931a8ad”]Yrs old

Tuberculosis: [field id=”field_3a99784″];&nbsp[field id=”field_b02ec80″]Yrs old


 

Have you ever suffered from skin problems?: [field id=”field_292cbbc”]

If yes please give details including age.

[field id=”field_c056679″]

Have you had any reaction to any inoculation?: [field id=”field_17d6386″]

If yes please give details including age.

[field id=”field_02f386e”]

Have you had any problems with thinking, concentration or memory?: [field id=”field_55e88b3″]

If yes please give details including age.

[field id=”field_1bc95ec”]


 

General Symptoms

Are you generally a hot or cold person? [field id=”field_b0985d6″]

What is your reaction to weather and temperature ( Dry, damp, hot, cold Etc..: [field id=”field_91af9f5″]

Do you perspire easily?: [field id=”field_da64b04″]

Please list any foods that you particularly love or hate, or cause you problems: [field id=”field_976b29f”]

Emotional Symptoms

How would you describe yourself?: [field id=”field_bda70ff”]

Please mention any strong emotions that you experience: [field id=”field_c569497″]

What would make you angry?: [field id=”field_cd54fde”]

How would you behave if angered?: [field id=”field_23a74ce”]

What makes you feel happy?: [field id=”field_3288c50″]

How would you behave if happy?: [field id=”field_984b8a4″]

Where do you feel happiest?: [field id=”field_748ddf4″]

Please list any repeating or significant dreams: [field id=”field_a67b059″]


 

Do you suffer from or have you ever suffered from the following?:

Allergies: [field id=”field_7a845e4″];&nbsp[field id=”field_9f16dbe”] Yrs old

Warts: [field id=”field_c2875dc”];&nbsp[field id=”field_137e328″] Yrs old

Moles: [field id=”field_56e5ad7″];&nbsp[field id=”field_feb5007″] Yrs old

Ringworm: [field id=”field_69a57ba”];&nbsp [field id=”field_281b1a1″] Yrs old

Cysts: [field id=”field_e148010″];&nbsp [field id=”field_26e948f”] Yrs old

Please provide brief details including month and year any operations, accidents serious illness or hospitalisation.

[field id=”field_d87d100″]


 

Please give details of current medication.

[field id=”field_7193a76″]

Please give details of previous medication.

[field id=”field_16bc98e”]


 

Please give details of close relatives’ illnesses including heart problems, Cancer, Diabetes, Tuberculosis, Mental IlnessAsthma, Eczema, Hay Fever Etc..

Father

[field id=”field_6bc14c7″]

Father’s Father

[field id=”field_1c7955b”]

Father’s Mother

[field id=”field_c96ac8a”]

Mother

[field id=”field_8a3c2e4″]

Mother’s Mother

[field id=”field_23ba959″]

Mother’s Father

[field id=”field_9c61a7f”]

Aunts and Uncles

[field id=”field_d6450aa”]

Brothers And Sisters

[field id=”field_3ada767″]


 

Nature and You

Where do you feel most at home? e.g. Countryside, mountains, rivers,bythe sea, cities…?

[field id=”field_1667a21″]

Do you like spending time in Nature if so how?

[field id=”field_e03eec1″]

Do you have a favourite plant, animal, bird, fish Etc.?

[field id=”field_8785976″]

What are your hobbies?

[field id=”field_456244f”]

Is there anything that your friends and family would like to say?

[field id=”field_3ada767″]

Brothers And Sisters

[field id=”field_3ada767″]