Adult New Patient Form - Classic Homeopath Registration

Adult New Patient

Please allow 30 minutes to complete this detailed new patient form. Please fill out as thoroughly as possible and do not leave any fields blank. The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.

Full Name *

Email Address *

Primary Phone *

Secondary Phone *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth *

Month

Day

Year

Referred by *

Gender *

Employment Status *

Occupation *

Employer Name *

Marital Status *

Number of Children

Emergency Contact Person *

Emergency Contact Phone *

Medical History

Hospitalizations: Give the following information for the last three times you have been hospitalized starting with the most recent (except normal pregnancies). Include type of illness, month and year hospitalized, name of hospital, city and state.Illness, Date, Hospital, Location.

AllergiesFoods, pets, pollens, molds, chemicals, medications, etc.

Current MedicationsType, dosage, frequency.

Currently used medicinal herbs, vitamins, teas.Name, dosage, frequency.

Homeopathic Remedies used/usingName, potency, frequency.

Personality and Preferences

Describe an ideal day in terms of weather and temperature

What are you most sensitive to? (eg. noise, odors, light, pain)

What are your fears?

Do you have any hobbies?

(Women only) What symptoms do you experience premenstrually?

Describe any recurrent dreams, important dreams in your life or recurrent themes in your dreams

How is your energy? Is there any particular time of day when it is lower or higher?

What environment do you feel most comfort in? (IE desert, mountains, ocean, city)

How is your sexual interest/drive?

What do you most like to eat or crave?

What is your favorite color?

What foods do you most dislike?

How is your thirst?

What temperature do you like fluids?

Are there any foods that you are sensitive to or allergic to?

Family History

Highlight all relatives with a history of this illness.

Questions, Comments, or Additional Information

Upload pictures, close up, full-length and candid, as well as any areas of concern (skin, etc.) Or email to tina@classichomeopath.com

Upload images of any art, drawings, writing, or any other creative activity and/or hobbies. Or email to tina@classichomeopath.com

Notice

The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.

Adult Registration Form