Intake Form

Medical & Personal History Form

In order to create an effective treatment plan as well as select the most appropriate homeopathic remedy, we would like to request that you supply our office with the information detailed below. Please write clearly or type the information on 8 1/2″ X 11″ paper and mail it to us at your earliest convenience before the appointment. Alternatively, you may email an attached document to the office at: homeopat@sover.net .

In the case of children or persons otherwise incapable of writing themselves, the responsible person is requested to supply the information as best as possible.

We are aware that the amount of information requested is quite extensive. Please do not let it overwhelm or deter you, simply respond as best as possible and focus on what you consider the most relevant information pertaining to you. Again, please keep in mind that the more accurate and forthright the information, the more useful it will be to properly evaluate your case.

PART I.

Please supply the following:

•  Full Name, Address, Date of Birth, Sex, Marital Status and contact information including home, work and cell phone numbers, email address and emergency contact information.

•  Family arrangement including names, ages and status (education/work/marital) of family members.

•  Educational background and status; current work status and previous employment history in brief.

PART II.

Describe in full what bothers you the most. For each complaint, describe the problem in detail.

Include a history of the trouble from the time of onset, its development, types of treatment taken and your response to them.

As much as possible, this description should include:

•  The area of the body affected, extension to other areas and how the location has evolved over time.

•  The sensation experienced in the region of the trouble.

•  Conditions that brought on the problem, including an examination of circumstances, physical and/or emotional, just before or during the onset of the problem.

•  Conditions or factors that increase or decrease the problem, including weather, season, time of day, diet, menstrual cycle, stresses, etc.

•  Other troubles experienced at the same time as the main complaint.

•  Describe as fully as possible other troubles you are currently experiencing or have experienced in the past.

PART III.

•  Provide a physical description of yourself including height and weight.

•  Describe your daily routine from rising getting up in the morning until going to sleep at night.

•  Describe in general how you react to the weather, seasons and temperatures.

•  Include your meal/food schedule, and relative quantities.

•  Describe your sleep, typical sleep schedule, position, as well as current and past history of sleep difficulties . .

•  Please list any relevant sexual history, habits or difficulties, including gynecological history.

•  Please list the number and type of dental fillings as well as other dental procedures such as root canals, etc

•  List any food or taste preferences and dislikes as well as foods that disagree with you. Also include any dietary regimens or diets your follow or have followed in the past.

•  Please list medications, prescription or over the counter, and dosages you are currently taking. Also, include vitamins, supplements or other natural therapies

PART IV.

•  Describe your nature and temperament, including relationships with family, friends and associates, your interests, aspirations and attainments as well as responsibilities.

•  Describe any dreams you may recall, especially recurring or particularly vivid ones.

•  List any current or past addictions or eating disorder.

PART IV.

•  List other illnesses that you have experienced and to what extent you believe these have a bearing on your current complaint(s).

•  Provide a history of the health status of your parents, sibling, spouse and children.

PART V.

Provide any other information not requested above that you feel may be relevant to this evaluation. This may include any familial, social, work related or financial stresses or responsibilities not otherwise listed above.

You are welcome to submit any other medical records, reports or tests relevant to your condition.