This is a general QUESTIONNAIRE used in Luc De Schepper's 'Hahnemann Revisited'. It may be used as a starting point, reproduced, or cusomized further.

Name:
Age:
Height:
Weight:

1. What is your chief complaint (CC)?
2. When did this problem begin? What happened in
your life around that time? What do you think
caused it?
3. What aggravates the CC? (certain types of
foods or weather, movement, light, noise,
heat/cold, or anything else that you can think
of; please be specific)
4. At what time of the day or night is the CC the
worst? Specify an hour if you can.
5. What symptoms can you identify that accompany
the CC (whether directly related or not)?

GENERAL QUESTIONS
6. Questions about the weather and environment:
you only need to answer those which apply to
you.
a. In which season does the weather bother you
the most?
b. How do you react to cold, hot, dry, wet or
windy weather? Please mention any and all
types of weather that affect you, and how.
c. How does a change of weather affect you?
d. How do you feel in bright sunlight?
e. Do you have any special reactions before,
during or after a storm? Please specify.
f. How do you react to drafts of air (e.g. open
window, having a fan on you) ? Do you like to
sleep with the window open even when it's cold
out?
g. How do you react to sudden changes in
temperature, e.g. going from a cold
environment to a hot room or vice versa?
h. What about warmth in general, warmth of the
bed, of the room, of the heater or stove?
i. How do you feel at the seashore, or on high
mountains?
7. What position do you dislike the most:
sitting, standing, lying?
8. Do you perspire a great deal? If so, when and
where on the body? (feet, head, hair, armpits,
etc)
9. What time of day tends to be a down time for
you?

MENTAL/EMOTIONAL
10. What do you worry about? How do you deal with
worries?
11. Do you tend to be neater and more fastidious
than those around you, or more casual?
12. Do you cry easily? In what situations?
13. When you are upset, do you tend to tell a lot
of people or keep it to yourself?
14. On what occasions do you feel despair?
15. In what circumstances do you feel jealous?
16. When and on what occasions do you feel
frightened or anxious? Any fears (darkness,
being alone, in crowds, altitude, flying,
elevators, etc.)?
17. What are the greatest griefs that you have
gone through in your life? How did you react?
18. What are the greatest joys you have had in
your life?
19. In what situations do you feel the blues,
depressed, sad, pessimistic?
20. What bothers you most in other people? How,
if at all, do you express it?
21. Do you have a lack of self confidence and a
poor sense of self worth?
22. Do you have any recurring dreams? What is the
theme?
23. What would you need to feel happy?
24. What do you do for work? Ideally, what would
you like to do?
25. If you had an unexpected week's vacation from
work and $1000, what would you do?
26. How do other people view you?
27. What would you like to change most about
yourself?

FOOD
28. How do you feel before, during and after
meals? How do you feel if you go without a
meal?
29. What would you most like to eat (if you did
not have to consider calories, fat, anything
you've read about the right way to eat)?
30. What foods do you dislike and refuse to eat?
What foods do you react badly to, and in what
way?
31. How much do you drink in a day? Include
sodas, juice, coffee, tea, milk, and
alcoholic beverages as well as water. How
thirsty do you tend to get?

SLEEP
32. What hours do you sleep? Do you tend to wake
up at a particular time? Why? What makes you
restless or sleepy?
33. Do you do anything during sleep? (speak,
laugh, shriek, toss about, grind your teeth,
snore)
34. How do you feel in the morning?

WOMEN
35. Number of pregnancies, number of children,
number of miscarriages, number of abortions
36. At what age did your menses begin? If you
have gone through menopause, at what age?
37. How frequently do they (or did they) come?
38. What about their duration, abundance, colour,
time of day when flow is greatest; any odour
or clots?
39. How do you (did you) feel before, during and
after menses?

HEALTH HISTORY
40. What medications are you taking at present?
41. How frequently do you get colds and flus?
42. Have you had any childhood illnesses twice,
or in a very severe form, or after puberty?
43. Have you had any vaccinations since the
standard childhood ones? Have you ever had an
adverse or unusual reaction to a vaccination?
44. Have you had any surgery? What and when?
45. Have you had at any time (mention year): What
therapy was given?
a) Warts: Where? When? How treated?
b) Cysts: Where? When? How treated?
c) Polyps: Where? When? How treated?
d) Tumours: Where? When? How treated?
46. Do you tend to have any discharges (nasal,
vaginal, etc.)? Colour, consistency?

SENSITIVITY
47. a) Do you tend to need a smaller dose of
medications than most other people?
b) Do you need less anaesthesia than others,
or have a hard time coming out of it?
c) Do you tend to react to vitamins and herbs
and/or need hypoallergenic vitamins?
d) Are you sensitive to paint fumes, exhuast,
dry cleaning fluid, fragrances etc.?

48. Family history: Mention diseases, causes
and ages of deaths of father, mother,
sisters, brothers and grandparents on both
sides.

49. Construct a time line: Mention from birth
on to the present day, all IMPORTANT events
(emotional and physical traumas,
heartbreaks, divorces, work-related events,
diseases or traumas your mother had while
being pregnant with you, family stress,
death in the family or of friends,
disappointment, etc.) Mention the symptoms
experienced at those moments or which you
can date to those traumas. Please try to
write at least one page outlining major
events of your life.
50. What else would you like to say about
yourself or your condition?