Homeopathy Intake Form - Part 2
Please fill this out as thoroughly as possible, as I frequently refer back to this info during and after each consultation.
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Please list all medicine, supplements, and homeopathic remedies you/your child is currently taking. *
Please list all PAST medicine, vaccines, and medical interventions (scans, surgeries, etc.). It is important to fill this and the next two fields out completely. *
Please list all CURRENT infections. If the pathogen is known please include that information (for example: throat infection/strep, skin infection/staph, UTI/e coli). *
Please list all PAST infections. If the pathogen is known please include that information (for example: throat infection/strep, skin infection/staph, UTI/e coli). *
Have you/the child been exposed to any toxins that you are aware of (heavy metals, unusual amount of radiation/EMF's, etc)? *
Mother's health history (include unusual vaccines, medical interventions, traumatic situations, etc. AND include any pertinent info about her pregnancy with you/your pregnancy with the child) *
Father's health history (include unusual vaccines, medical interventions, traumatic situations, etc.) *
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