Lyme Disease Questionnaire - HomeopathicVibes

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Our Address: 940 E El Camino Real, Sunnyvale, CA - 94087 | 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538

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Lyme Disease Questionnaire

Why Me?

I'm providing homeopathic services for over 20 years in entire California. My clinic is located in Sunnyvale, Fremont, and San Jose. I have treated more than 1000 patients suffering from various conditions. I also provide online consultation if you're not able to visit any of my clinics. I have more than 100 five stars reviews on Google, Yelp, and other reviews websites. If you would like to know more about me, then feel free to reach me out by phone.

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Lyme Disease 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 *

First

Last

Email *

Do you think you were ever bitten by a tick?

Yes
No

What body part was bitten by tick?

Did you had a red circular rash right after bite?

Yes
No

Explain size if yes?

Do you have any Facial pain or tingling of nose, cheek or face?

Yes
No

Do you have any twitching of the face?

Yes
No

Do you have stiffness of neck or head area?

Yes
No

Do you have stiffness of Jaw or TMJ joint?

Yes
No

Did you ever have sore throat or gum disease?

Yes
No

Do you have any eye pain swelling around the eyes?

Yes
No

Do you have any floaters blurry vision or double vision?

Yes
No

Your hearing is impaired or improved in the past?

Yes
No

Have you noticed any ringing or buzzing of ears in the past?

Yes
No

Did you ever have irritable bladder or urinary incontinence?

Yes
No

Do you have stomach upset, nausea or pain?

Yes
No

How often you have stomach upset, nausea or pain if yes?

Yes
No

Less than once a week, more often or always?

Are you having any bowel problems Diarrhea /Constipation?

Yes
No

Please explain

Mood swings / Irritability

Yes
No

Short temper ness /Cry easily

Yes
No

Sleep a little or sleep too much

Yes
No

Have difficulty in falling sleep

Yes
No

Difficulty in concentrating?

Yes
No

Do you often feel disorientated?

Yes
No

Did you have any issues with speech?

Yes
No

Any chest pain or shortness of breath.

Yes
No

Dry or productive cough.

Yes
No

Heart palpitations/Anxiety/panic attacks

Yes
No

Any night sweats

Yes
No

Muscle pain/Cramps/soreness of legs

Yes
No

Joint swelling worst during day

Yes
No

Joint swelling worst during night.

Yes
No

What kind of lab test have you done so for? Please Explain

What medicines have you taken for your so for?

Did you ever consulted any Homeopath in the past if yes, what did he/she treated you with?

How long have you been on the medicine?

Name

About Me

I have passion for homeopathy. I am blessed to be born in family of Homeopaths. My grand father Dr. Hazara Singh Gill was great homeopath of his times. He did his M.B.H (Bachelor of Medicine in Homeopathy) from Punjab Homeopathic Medical College Lahore in 1925.

Sunnyvale Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 940 E El Camino Real, Sunnyvale, CA 94087, United States
harminder@homeopathicvibes.com

Fremont Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538, USA.
harminder@homeopathicvibes.com

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