Ask A Homeopath - Dr. Alva Irish

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The fee for a complete Work Up is $225. This includes Hair and Facial Analysis. You must complete all questions below. You will need to pay prior to submitting
your completed questionnaire. Once you complete the payment section please return to this page to answer questions. The Doctor will notify you via return e-mail
when your analysis is complete. Please read the instructions again to make sure you follow all directions.

Please fill out this form in it's entirety and submit by clicking on "submit query" at the bottom. You may mail your hair samples along with
your photo to the address at the bottom. Or if you prefer and have a digital picture, you can email the photo to Dr. Irish at: Dr.Irish@askahomeopath.net

Homeopathic Health Questionaire
Your Name
Street Address
City
State
Zip Code
Telephone Number
Email
Physician's Name/Address/Phone
Medical Diagnosis
What are your typical days worth of meals? - Breakfast
Snack
Lunch
Snack
Supper
Snack
Allergies
Age
Height
Weight
Blood Pressure
Blood Sugar
Prescriptions/Medications taking now
Prescriptions taken in the past
Surgeries?	Yes No
If yes above, please explain details
Please list ALL food supplements, vitamins, herbs, etc., you are taking now
Have you ever taken, or are you now taking ANY Homeopathic remedies?	Yes No
If so, what were they, when did you take them, how many doses, and what potency of each
List all complaints you have anywhere on your right side, from head to foot
List all complaints you have anywhere on your Left side, from head to foot
Constipation?	Yes No
If Yes, please describe the color and consistency, odor
Does your abdomen make sounds before?	Yes No
Do you have Cramps before?	Yes No
Do you have involuntary stool?	Yes No
If Yes, when?
Do you have involuntary Stools when you urinate?	Yes No
When you pass gas?	Yes No
Piles? Bleeding?	Yes No
When are all your symptoms worse?
What makes them better?
Mental Symptoms
Other Mental Symptoms	Depressed Elated Bi-Polar Seizures
Head Symptoms
Scalp
Hair
Eruptions/Dandruff/Scabs/Sores/Redness/Scaldhead:
Face/Eyes/Vision
Lid Appearance	Swollen Upper Lower Both Sties Warts/Growths
Location
Do you smoke?	Yes No
Use Alcohol?	Yes No
Other Drugs?
Nose Perforated?	Yes No
Nose Appearance
Ears
Hearing
Tongue
Mouth - Inner
Mouth - Lips
Throat
Uvula
Do you snore?	Yes No
Sleep Position
Are you sleepless?	Yes No
Do you want to sleep all the time?	Yes No
During the day?	Yes No
Are you sleepy after meals?	Yes No
Teeth Decay?	Yes No
If yes, describe
Neck
Chest
Ribs
Heart
Veins/Arteries
What foods do you HATE?
What foods do you CRAVE?
What foods do you like, but don't like you?
Food allergies
Craving odd things, chalk, pencil lead, etc.
Stomach
Abdomen
Liver
Spleen
Gall Bladder
Check any fears you have	Cats Dogs Rats Elevators Riding in cars Heights Snakes Spiders Birds Other
What does your sweat smell like?
Feet smell?
Underarm smell?
Is your furnace new?	Yes No
What kind of furnace is it?
Do you cook with:	Gas Electric Fireplace Gas/Electric
Ever been exposed to petroleum? Describe
Do you use petroleum products?
Are you sensitive to the sun, and if so, what happens?
Are you worse in the heat or worse in the cold? What happens?
Any symptoms related to your:	Legs Arms Hands Fingers Forearms Wrists Knees Achilles Tendons Feet Tendons Leg Cramps
Any of the above - when and where?
Do you, or have you ever had cancer?	Yes No
If so, where?
Do you have a tumor, and if so, where?
Warts? Where?
	Veneral Warts Venereal Disease Growths of any kind Moles Birthmarks
If any of the above, describe color
Do you have Vitiligo?
Any other markings on your face?
Do you hate people?	Yes No
Would you rather be alone or with people?
Are you worse when you are getting warm in bed?
After eating sugar?
During the day or night?
What happened right before your problems started?
How old were you when your problems started?
Tell me what happened

Please pay in advance through the order form, then submit this form and send hair samples and waiver through the mail. You may send the photos along with them or
email them.

Dr. Alva Irish, 236 Fuller Drive Easley, SC 29640
Phone: 864-605-0474
Offices in Greenville SC, Spartanburg SC, Anderson SC and Columbia SC.

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