Adult Intake Form

Please complete the intake form below prior to your appointment.
All information you share is kept confidential.

Adult Intake – Homeopathy

Newsletter

First Name

Last Name

Phone number

Date of Birth

Sex

What brings you in today?

When did this issue begin?

What makes it better or worse?

Are there any other physical symptoms or conditions you experience?

Please include anything you feel may be related, even if it seems minor.

Have you been diagnosed with any medical conditions in the past?

Have you had any surgeries, hospitalizations, or major illnesses? Please include approximate dates if known.

Are you currently under the care of a medical doctor or specialist?

Please list all medications you are currently taking, including prescription, over-the-counter, and as-needed medications.

Please list any supplements, herbs, or natural remedies you are currently using.

Do you have any known allergies or sensitivities?

How is your sleep overall?

How is your appetite and digestion?

Alcohol, caffeine, tobacco

How is your thirst?

How is your energy throughout the day?

Occupation & daily routine

Are you sensitive to heat, cold, weather changes, or drafts?

Are your menstrual cycles regular?

Do you experience pain, PMS, or other symptoms with your period?

Have you noticed any changes in your cycle over time?

Are you currently pregnant, breastfeeding, or trying to conceive?

Have you used hormonal birth control or hormone therapy (past or present)? Please specify.

If applicable, are you experiencing perimenopausal or menopausal symptoms?

How would you describe your emotional state recently?

How do you typically respond to stress or pressure?

Are there any recurring worries, fears, or emotional patterns you notice?

Have there been any significant emotional events or life changes?

Disclosure and Informed Consent:

Homeopathy is a system of complementary care and is not intended to replace medical diagnosis, treatment, or emergency care.

Homeopathic care is individualized, and responses to treatment vary from person to person. No guarantees are made regarding specific outcomes.

I confirm that the information I have provided is accurate and I consent to receive homeopathic services from Homeopathy for Better Health.

Consent & Authorization

I have read and understand the information above and consent to receive homeopathic services from Homeopathy for Better Health.

Full Name (Electronic Signature)

Date