Navigation

PLEASE NOTE:
The mechanisms that allow this survey to be submitted automatically are temporally down. In the mean time, you may fill out this form and either:

Cut and paste it into an email for Dr. Silvestri: drkennethsilvestri@gmail.com
Or print this page.

Homeopathic Survey

Basic Info

Name
Street
City
State
Zip

Phone
Email
Height
Weight
Date of Birth: - -

Questions

Describe your symptoms (i.e. type of pain, feeling etc); include what you think was the cause, when it started, where/when it affects you and how long you have had it.
What aggravates it and makes it better (i.e. food, weather, noise, movement, time of day etc)?
How do you act react to being cold and/or hot?
How do you deal with stress (include your decision making style)?
How do you display your emotions (i.e. anger, jealousy, grief, depression, phobias etc)?
Describe your temperament (i.e. angry, calm, sensitive, nervous or any combinations).
Describe any fears and anxieties you may have (i.e. darkness, heights, anticipation, obsessions etc).
How do others describe you?
How do you rate your self esteem and confidence?
Describe your communication style (i.e. assertive, aggressive, passive, etc).
How do you organize yourself and what bothers you most about others (include how do you deal with it)?
What do you do for work and/or what would you like to do?
List any food cravings and aversions.
Are you thirsty for cold or hot drinks?
What type of weather do you like?
Are you better or worse from certain activities?
What is your history of medications (include any sensitivity or allergic reactions to specific things)?
What is your physical shape?
Is there any T.B. or sexually transmitted diseases in your history or in your family?
What is your family medical history (i.e. causes of death of immediate family, illnesses, etc).?
From birth to present, give a time line of all important traumas/crises both emotional and physical (i.e. heartbreaks, illness, divorce, surgeries etc).
Do you perspire a lot? When, where?
How do you react to sunlight?
What is your sleep pattern (i.e. when, what position, disruptions etc).?
Describe your dreams.
Are there any sexual issues in your life?
Describe your diet in general.
Female menses- age first began, patterns, duration, color/clots, etc.
Number of pregnancies.
Gastrointestinal symptoms (i.e. bloating, how, when, etc)?
Have you had warts, cysts, polyps, tumors, skin disorders or allergies (how were they treated)?
Describe any unusual, specific and/or peculiar symptoms (i.e. headaches, vision, ears, unusual sensations, emotions or thoughts etc) that best portray you?