Adult Intake Form

ADULT INTAKE FORM FOR NEW PATIENTS
Today's Date

DayMonthYear
Date
Personal Information
Full Name*

First NameMiddle NameLast Name
Email
Birthdate

DayMonthYear
Home Phone Number
Format: (000) 000-0000.
Other Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex / Gender / Pronoun
SingleMarriedSeparatedDivorcedCommon-Law PartnerWidowedIn a PolygamyOther
Occupation
Employer
Referral
OCHMFamilyFriendHospitalDoctorInsurance PlanClose to Home / WorkYellow PagesOther
Name of Family Physician
Phone Number of Family Physician
Please enter a valid phone number.Format: (000) 000-0000.
Name of Homeopath if referred
Phone Number of referring Homeopath
Please enter a valid phone number.Format: (000) 000-0000.
In Case of Emergency

We will contact the person below in case of an emergency.
Name of Local Relative or Friend
Relationship to Patient
Home Phone Number of Emergency Contact
Format: (000) 000-0000.
Work Phone Number of Emergency Contact
Format: (000) 000-0000.
Vital Statistics

(if known)
Height
In Feet + Inches or Centimeters
Weight
in Kilograms
Blood Pressure
Systolic Over Diastolic. Example : 120/90
Pulse
Date of Last menstrual period

DayMonthYear
Age of first menses
Number of Pregnancies
Number of Miscarriages or Abortions
Allergies
Health History
What is Your Main Concern?
When did it start?
Example: A year ago, 3 months ago, (or put exact date)
Did your illness start after an event, accident or mental upset? Such as shock, worry, dietary, overexertion, weather?
Does anything make it better? Worse?
Do you have any other health concerns? Please list in order of importance for you.
AbscessesAlcoholismAnemiaAppendicitisArthritisAsthmaCancerChicken PoxCold soresDepressionDiabetesEczemaEpilepsyEmphysemaGall stonesGoitreGonorrhoeaGoutHeadachesHeart troubleHypertensionHepatitisHerpesInfluenzaJaundiceKidney DiseaseLeukemiaLiver DiseaseMalariaMeaslesMental IllnessMononucleosisMumpsNosebleedsParasitesPelvic inflammatory diseasePneumoniaProstate DiseaseRheumatic FeverSexual AbuseSkin DiseaseStrep ThroatSinusitisStrokeSyphilisTonsillitisTubercolosisVenereal WartsWartsWhooping CoughWormsOther

How much of these substances do you use ( per day / week / month )?

Rows	Per Day	Per Week	Per Month
Tobacco
Coffee
Alcohol
Recreational Drugs

What vaccinations did you have? Any bad reactions?
What exercise do you do and how much?

List any treatments, medicines, supplements, homeopathic remedies you are taking.

Rows	Treatment or Medicine	When and for how long?	Effect on you
1
2
3
4
5

Any Major Surgeries?

Rows	Surgery	When?	Complications
1
2
3
4
5

Any Major Injuries?

Rows	Surgery	When?	Complications or long term effects?
1
2
3
4
5

Family History
Alzheimer'sAlcoholismAsthmaArthritisCancerDiabetesDepressionEpilepsyGonorrhoeaHypertensionHeart DiseaseHepatitisMental IllnessPneumoniaSkin DiseasesSyphilisTuberculosisUlcersOther

Relationships

Rows	Current Age	Age at Death	Cause of Death	Disease(s)
Mother
Maternal Grandfather
Maternal Grandmother
Father
Paternal Grandfather
Paternal Grandmother
Sister(s)
Brother(s)
Aunt(s) / Uncle(s)
Children

Services and Fees

Initial Assessment (1.5 - 2 hours)
(consultation and remedy, a one time fee, unless treatment is restarted after 1.5 years) - $350

Follow-up visit (45 minutes)
Children age 10 and under - $90
Adults (50 minutes) - $120

* Prices typically include cost of a constitutional remedy if required and are usually held once a month for the first six months of treatment to make sure things are progressively as effectively and efficiently as possible. After 6 months, visits are spread out farther depending on progress and how much support you need.

Prices listed do not include HST

Detox remedies and rare remedies as well as delivery or courrier charges may be extra and can be ordered by patients from a dispensary or from Joy directly.

Acute conditions
Homeopathic Labour induction - $50
Telephone consultations - $30/15 minutes

Email updates about your progress are welcome and are responded to free of charge if it is a simple issue relevant to our last visit. If I feel that I require more information to provide you with the best care, beyond email, I will request a further consultation, which will be charged at the normal rate.

CONSENT FORM
Homeopathy is a system of medicine founded by Dr. Samuel Hahnemann (1755-1843) of Germany. It is based on the principle that “like cures like”. In practice, this means that a medicine capable of producing certain effects when taken by a healthy human being is capable of curing any illness that displays similar effects.

Another fundamental principle of Homeopathy is that it treats the patient as a whole and as an individual. There is no medicine for a particular disease. There is a medicine for the person suffering from the disease. The homeopath takes into consideration all the symptoms that distinguish a person as an individual. This includes details of the patient’s past and family history, temperament, dietary habits, sleep, etc.

1. I fully understand what has been explained to me in regards to:
- The nature of homeopathic medicines (remedies)
- The safety of homeopathic remedies and possibility of short-term physical or mental aggravations
2. I acknowledge and declare that:
- The decision to seek homeopathic treatment is solely my decision
- I have not been advised at any time to stop seeking allopathic treatment (medical doctor or MD), and that standard medical treatment must be obtained from a medical doctor
- I accept full responsibility for fees incurred during care and treatment, and agree that payment is due when services are rendered (at the end of each visit), unless prior arrangements have been made. This includes a charge of the whole appointment fee, for missed appointments unless 24 hours notice has been given.
- I will clarify any questions I have about my treatment with my homeopathic practitioner.
  Joy Burlton is currently registered and in good standing with the College of Homoepaths of Ontario reg # 15258
All information disclosed is confidential and remains protected according to the Privacy Act of Ontario.
I, First Name* Last Name* have read, understood and acknowledge the above statements.

Witness : First Name* Last Name*
Signature*

Clear
Date Signed*

DayMonthYear
Date
Should be Empty:

ADULT INTAKE FORM FOR NEW PATIENTS

Personal Information

Referral

In Case of Emergency

Vital Statistics

Health History

Family History

CONSENT FORM