Follow up Consultation Form

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

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1. Did any of your existing symptoms improve since your appointment with us? If so, which ones?

2. Any new complaints or symptoms that have appeared? If so, which ones?

3. Did any of your symptoms worsen? Which ones and to what degree?

4. Are you following my advice on diets and life style? If yes, to what level are you following?

5. Did any new events (stress, physical or emotional events) happen between your last visit and now that have affected you?

6. Are you dealing with real life stress any differently since the last appointment?

7. How has your mood been? How is your energy level since your last appointment? Did it improve or become worst?

8. Have you made any changes to your diet or eating more or less the same?

9. How is your sleep? Any changes in your sleep pattern since your last appointment more or less hours, restless, deeper, sounder sleep, etc?

10. Any new tests or other doctor visits to report? Have you done anything new in-between visits (i.e. started herbs, acupuncture, any new remedy etc)?

11. How are you feeling about your self in general?

12. Anything else you want to communicate? Please use this question to add any other detail that you want to communicate to me.

13. Have you finished all your medicines including liquid medicines?

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