1 Chief Complaint: Describe your chief complaint – your main reason for coming for the consultation – in full detail; ie, when and how it began, its diagnosis (if you have one), all signs (physical changes) and symptoms/sensations associated with it, referring to the descriptive headings below (if a skin complaint, also refer to item 7 below):
a. Quality of pain/sensation (eg, dull, ache, pulsating/throbbing, burning, cutting, stitching, numbness, tingling, crawling, coldness, heat, etc.)
b. Location of pain/sensation.
c. Does the pain/sensation extend to another part of the body?
d. What makes the pain/sensation feel better or worse (homeopaths call these modalities)?
Heat or cold (air temperature, room temperature, applications, baths)?
Weather or weather changes?
Time of day or night?
Position (standing, sitting, lying – in what position, etc.)?
Activity (walking, running, driving/riding, bending, rising, ascending or descending stairs, reaching, turning, lifting, sleeping, waking, jarring, etc)?
Touch, rubbing, pressure (hard or light, clothing?
Eating or drinking (if so, what in particular – hot/cold drinks, type of food)?
Bodily functions (menstrual period, sweating, salivating, urination, defecation, coughing, sneezing, etc.)?
Other exposures (light, sunlight, noise, odors, music, conversation)?
e. And, finally, are there any associated symptoms/conditions that tend to occur with the complaint (homeopaths call these “concomitants”)? Examples: abdominal bloating, salivation, chills, etc.

Comment on the previous treatment this complaint (and others) has received.

2 Past Medical History: Mention all previous illnesses. A complete history of your health is important, even of such things as skin diseases, children's diseases and their after-effects; tell of fevers, colds, flus, sores, ulcers, etc.; also injuries, if any. Tell their location and what treatment was used.

3 Additional Complaints: Describe all additional health complaints – you may reserve mental-emotional complaints for a later section, and provide all relevant details (modalities, etc) of each as requested for the chief complaint. Also, describe how your sense of vitality, well-being is, your energy level and what affects it for the better or worse.

4 Mental-Emotional Characteristics
If mental-emotional distress troubles you, please provide as full a description as you can, mentioning how you feel, how the problem seemed to begin and the apparent cause, what makes you feel better or worse (this could be any of the modalities mentioned in item 1 or it could consist of other influences; eg, consolation, company, being alone, anger, specific types of stress, overwork, humiliation, criticism, etc.)
Tell of any emotional shocks, frights, disappointments, etc. of the present or past.
Provide a thorough description of yourself – your character and personality, as best you can. For example, are you outgoing or introverted, a loner or quite sociable, shy, timid, confident, assertive, arrogant, calm, angry, aggressive, anxious, melancholy, moody, cheerful, humorous, serious, talkative, quiet, industrious, impatient, hurried, lazy, slow, content or discontent, easily offended and sensitive to criticism or impervious to same, engaged and curious, neat or sloppy, bored and indifferent whatever you can think of. If you have trouble thinking of things to say, try to recall what friends and family have said about you, or even ask them to write-up their own description of you.
Have you any fears? For example, heights, claustrophobia, darkness, robbers, animals, insects, snakes, water, storms, airplanes, crowds, sight of blood, public speaking, death, disease, germs, being alone, performing, rejection, criticism, death of a loved one, horrible/violent sights (real or in the media), etc.
How is your mental functioning and memory?
How to do you feel about your work/career/school?
How do you feel about your relationships/marriage/family?
What are your dissatisfactions in life, your goals, your joys?
What do you like least/most about yourself?
What are your favorite hobbies or pastimes (eg, crafts, music, reading, travel, sports, etc)?

5 Generalities: “Generalities” is the term homeopaths apply to the modalities of the whole person, as opposed to specific complaints. Using all the modality descriptors listed in item 1, comment upon how you as a person, in general are affected by various influences, stimuli, and activities, if remarkable. For example, are you chilly or warm-natured; affected by weather or storms (approaching or present), drafts, sunlight, clouds, humidity; affected much by eating or drinking; by time of day or night; perspiration; getting wet; menstrual period; resting; activity; exercise; occupation; thinking; meditating; the ocean or mountains. Do any of these or anything else make you feel significantly better or worse?

6 Food/Drink
How strong or weak is your appetite and thirst? Do you get hungry or thirsty at any specific or unusual time?
Tell what is strongly craved or disliked, including such things as salt, sweets, fats, sour, spicy things, eggs, milk, cheese, ice cream, chocolate, meats, fish, chicken, fruits, vegetables, onions, garlic, soup, ice, cold things, warm things, bread, etc. Also, what drink is preferred?

7 Skin: In skin, scalp, or nail problems, tell the exact location, color, whether dry or moist, thick or thin, scaly, crippled, pimply, with or without matter, warts or growths, appearance of surrounding skin; whether itching, burning, worse or better from scratching, and what else makes it better, such as heat, the heat of the bed, cold, exercise, wool, water, etc. Tell of any enlarged veins, unusual bruising, etc.

8 Discharges: Describe discharges of any part, whether slight or heavy, the color, odor; if thick or thin, gluey or sticky; if causing redness or burning, rawness; color or stain; and what makes it better or worse and when.

9 Urine: Is there urinary tract pain before, during or after passing, color, odor, appearance, quantity, sediment, frequency, urgency (if hurried).

10 Bowel condition/Elimination: What is the stool’s appearance: color, odor, consistency (hard, dry, large, pasty, bloody, frothy, slimy, thin, watery, slender, flat, etc.)? How often, at what times worse or better, or how affected by certain circumstances; whether difficult, incomplete, urging without result; if the stool slips back in, if prevented by spasm of the rectum; or anything else peculiar.

11 Menstrual History: Woman are to give age at first menstrual period, how far apart then and now; whether pain before, during, or after, then and now, and where; also where the pain may extend to, as to the back, sides, groins, thighs, etc. What kind of pain), what relieves or aggravates, how often the pains come. If you have experienced PMS (premenstrual syndrome), please describe all of the symptoms associated with it. Tell whether there have been miscarriages. Tell how you feel in general, before, during and after the periods; sex desire or aversion, frequency of masturbation (at your discretion, of course), whether intercourse is normal, unsatisfactory, or painful; masturbation frequency, etc. Please also describe how any past pregnancies affected you.

12 Males: Men are to give particulars as to male organs, if anything is not normal; whether there’s been a history of any former disease; effect of intercourse; strength of sexual drive; frequency of masturbation (at your discretion, of course); whether night emissions, etc.

13 Sleep: Describe the details of your sleep. Do you sleep well or poorly? Do you have trouble falling asleep or staying asleep? Do you waken at a certain hour? In what manner; e.g., as from fright, from a dream, from a sensation of heat, from a physical pain or other sensation? In what position do you sleep? Do you stay covered or uncover? Do you uncover your feet at night? Are there any peculiarities associated with sleep, such as teeth grinding, perspiration, salivation (drooling), jerking, restlessness, talking or walking? Do you dream? Do you have any recurring dreams or dreams of a similar nature; i.e., similar theme, same object or person recurringly appears, etc.? Mention any other peculiarities of sleep. How do you feel on waking in the morning?

14 Summary: Lastly, but most importantly, if you are willing, using the guidelines given above, please write a narrative summarizing your principle complaints and the "reason" you think you became ill. Do you think your life situation at the time or now, any stress you may have been exposed to, any qualities in yourself might have contributed to your illness. Similarly, did any physical, chemical, or biologic trauma contribute? Describe the significance of your illness to you, what your emotional reaction to it is, what your worries in regard to it are. And also, describe yourself (separate from the illness), what you feel are your central personal strengths and weaknesses; include a summary of your life history focusing upon the most important events in your life — major griefs and losses, disappointments, the worst thing(s) that has happened to you, your childhood. There may be overlap with your answers to item 4 above, in which case there’s no need to repeat yourself here. Discuss what is most important to you in life.

And that’s all! Whew! We know what an effort it is to describe yourself and your symptoms in the details necessary for a homeopathic interview, and we appreciate your labours. This will greatly assure us that some important detail has not been left out. When you arrive at the office, Dr. Guess will review your write-up before conferring with you in person, a process that usually takes about thirty minutes or so. Thank you.