Homeobotanical Consultation Form

Your Details

Full Name *

Date of Birth

Phone Number

Email Address

Home Address

Presenting Problem

Please describe the main reason you are seeking Homeobotanical / HomeoHerbal support.

Were you under stress when you first noticed this problem?

Yes No Unsure

Are you seeing any other specialist about this problem? If so, who?

Are you taking any medication for this or any other issue?

Symptoms

Please tick any of the following that apply to you, and add detail in the notes boxes below.

Itching — where on the body?

Pain or tightness — where on the body?

Any other symptoms not listed above

Is your current situation stressful?

Yes No Somewhat

Medical History

Please indicate Yes / No / Past for each of the following.

Allergies

Under Medication

Do you smoke?

TB / Lung disorders

Pregnancy

Depression

Operations / Surgery

High / Low Blood Pressure

Injuries

Arthritis / Rheumatism

Asthma / Eczema

Schizophrenia

Cancer

Diabetes

Please give details for any Yes / Past answers above

Any other major health problems not listed above

Family History

Please note any health conditions relevant to your presenting problem in close relatives.

Father

Mother

Grandfather/s

Grandmother/s

Other relatives & Children

Lifestyle

What is your diet like?

What exercise do you do?

Do you enjoy your job?

Yes No Mostly N/A

Is your home life stressful?

Yes No Sometimes

Additional Comments

Please add anything else you feel is relevant to your health or treatment.

Signature & Declaration

In compliance with the various Statutes and Regulations, no specific claims are made for the application or use of Homeobotanical and HomeoHerbal preparations. The blends are Dietary Supplements designed by a qualified practitioner for use as part of a comprehensive care programme.

Please sign below to fully accept responsibility for your own health.

Signature (type full name)

Date

How to Return This Form

Once completed, please save as a PDF and email it back to your practitioner:

Click Save as PDF below — this opens your browser's print window
Change the Destination / Printer to "Save as PDF" (or "Microsoft Print to PDF" on Windows)
Click Save and choose where to save it on your device
Email the saved PDF to your practitioner

On a phone or tablet: tap the Share/Print icon in your browser → choose Print → pinch-zoom out → Save as PDF

Tip: In the print window, set Paper size to A4 and turn off Headers and footers for the cleanest result. The form will flow as one continuous document.