If you prefer to complete the PDF form, please Download, complete and email the in-take forms to firstname.lastname@example.org or bring it with you for your appointment.
This questionnaire is a confidential health assessment tool, which will assist in treating you safely. This will also give me brief information about your health history before our online or in-person appointment. Please take the time to answer the questions as accurately as possible.
All fields with * are mandatory.
First Name (*)
Postal code (*)
Date of birth (*)
Marital Status (*)
Number of children (*)
Family physician’s name and contact number
Please provide the name and contact information of an individual that we can contact in case of emergency. (name, relationship, contact number)
Has your child been treated with homeopathy before? if yes, please provide the name of the homeopath.
How did you hear about our homeopathic clinic? (internet, magazine/newspaper, referred by)
Please give me a brief history about what brings you to homeopathy.
If you have any health concern, please list in order of importance to you.
Can you trace the origin of the present illness to any particular Circumstance such as accident, Illness, Incident? (E.g. Shock, Trauma, Worry, Errors In Diet, overexertion, exposure To Cold, Heat, Etc)
Please list any major surgeries you have had in the past.
Have you had any injuries?
Have you been vaccinated? Y ̈ N ̈ If yes, did you have any adverse reaction?
Have you lost any weight recently? Y ̈ N ̈ If yes, How Much?
Date of last annual physical exam /blood test:
Do you have any Internal Pins/Wires, Artificial Limbs, Special Equipment? Y ̈ N ̈ Please explain:
Any allergies/sensitivities (foods, drugs, pets, seasonal, etc.):
Have you been diagnosed with any specific disease or condition in the past?
Please list any medication or supplements including homeopathic medicine or herbal medicines that you are already taking.
Is your occupation is associated with any potential life/ health threatening condition? Please specify.
Have you experienced any Stress, Trauma, Loss or Life Changing Trauma in your life?
Please check which of the following substances you are currently using.
Alcohol how much?
Recreational drugs how much?
Sleeping pills how much?
Laxatives/Purgatives how much?
Pain killers how much?
Cigarettes how much?
Coffee or tea? How much?
Is your child is on any special diet? Y ̈ N ̈ Explain:
How many hours of sleep do you get each night?
Do you wake in the night for any particular reason?
At any particular time? How long does it take to fall back asleep?
Do you wake feeling Rested? Y N
General energy level out of 10 (1=lowest, 10=highest)
Please check any of the following ailments which may be present in your family history:
Please check ailments which may be present in your child’s family history:
Material grand father
Paternal grand mother
paternal grand father
Is there anything else that you feel that hasn’t been addressed on this form?
Please leave this field empty.