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Dr Kenneth Silvestri
Homeopathic Survey
Basic Info
Name
Street
City
State
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
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Hawaii
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Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
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New York
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Northern Mariana Islands
Ohio
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Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Phone
Email
Height
2'
3'
4'
5'
6'
7'
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight
Date of Birth
January
February
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June
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1
2
3
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5
6
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14
15
16
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18
19
20
21
22
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24
25
26
27
28
29
30
31
-
2009
2008
2007
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2002
2001
2000
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1996
1995
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1992
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1911
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1905
1904
1903
1902
1901
1900
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?
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