Abdominal Follow up Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *Phone *How often you are taking the remedy? How many pills a day? How many drops from the bottle. Did any of your existing symptoms improve since your appointment with us? If so, which ones? Have you had any flare ups or new symptoms since your last visit? YesNoDid any of your symptoms worsen? Which ones and to what degree? YesNoDid any new events (stress, physical or emotional events) happen between your last visit and now that have affected you? YesNoHow may bowel movements you are experiencing in a day since your last visit? Less than 4 4-67-10More than 10 Do you still have urgency to run for passing stool? Yes NoNever Have you been experiencing any abdominal pain or cramps since your last visit? Yes NoNever Have you noticed any blood in your stools since last visit? Yes NoHave you noticed any pus or mucous in your stools since last visit? Yes NoSince your last visit which area of your life has been negatively affected by your symptoms? Nothing Caused me to miss work or school Caused me to miss or decline social activitiesMade me anxious or depressed. How would you rate you health level today and last visit? Number One being poor and ten being prefect health? Today Last visitAnything else you want to communicate? Please use this question to add any other detail that you wantto communicate to me. EmailSubmit