Homeopathy Feedback Form
To be filled out approximately 2 weeks after starting any new protocol, so that I can make any changes to the protocol for the following 2-3 weeks.
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Email *
Who is this feedback form for/about? *
If different than above, what is your name? *
Are you filling this out after an initial consultation or a follow-up consultation? *
Please "categorize" your symptoms in your mind as you are filling this form out. These are the categories: 1. Symptoms which have improved in frequency and/or intensity, 2. Symptoms that have worsened in frequency and/or intensity, 3. Return of old symptoms (symptoms you have experienced in the past but have been gone), 4. New symptoms you have never experienced before, and 5. Symptoms that have stayed the same. I will be asking about each of these categories below, please try to list them in the proper category so that I can ascertain the direction your case is going.
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Did you witness any mild, moderate, or substantial improvements/gains in any of the cognitive/emotional/behavioral/physical features of the case we discussed? *
Please list and expain any improvement in case features (include changes in frequency and/or severity). For example: He is more focused but only in the morning...Hyperactivity is cut in half...She is having 2 rages per week instead of daily...Skin rash is still here but less intense (so tell me how much the symptom has changed). *
Did you witness any mild, moderate, or substantial worsening of any of the cognitive/emotional/behavioral/physical features of the case we discussed? *
Please list any worsening of features of the case (include changes in frequency and/or severity). Also include any OLD symptoms that have come back. For example: Hyperactivity is more intense...Skin rash has come back...Pain in hip is happening 3 times per week instead of once per week like before... *
Which symptoms/features remain untouched (no improvement or worsening)? Include cognitive, emotional/behavioral, and physical features. *
Have any new features developed that you have never had before? Example: I am having trouble falling asleep...I have a rash I have never seen before...I have a runny nose.
If you were given 2 or more remedies on your protocol, were you able to differentiate how each one was affecting the case? For example, did one remedy affect one feature, and the other remedy affect a different feature? *
What is your overall impression of the response to the remedies? Overall better, overall worse, overall no change? Please explain. *
For those filling out this feedback form after the INITIAL CONSULTATION: we will discuss your feedback and I will make any necessary changes during our free 15-minute follow-up. If you have not scheduled that yet, see the scheduling link in my email signature to schedule that now (or go to the services tab on my website to schedule: stephanienewtonhomeopathy.com).
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For those filling out this feedback form after a FOLLOW-UP CONSULTATION: I will be in touch on email within 48 business hours of receiving this form with any changes you should make to the protocol. At that time you should schedule a follow-up appointment about 2-3 weeks after implementing those changes. You can schedule that using the scheduling link in my email signature
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