Adult-Adolescent Homeopathic Intake Form

Health History Form

LDC Wellness - Adult/Adolescent Homeopathic Intake Form
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Email Address
example@example.com
Date of Birth*
Example: January 1, 2000
Referred by:
Current family doctor and phone number
Major complaints in order of importance for you:*
Are you currently under the care of a physician(s)?
What other treatments or regimes are you currently following?
Which medications are you currently taking?
Check the conditions that you have had:

AbscessesAlcoholismAllergiesAmnesiaArthritisAsthmaCancerChicken PoxCold SoresColitisDepressionDiabetesEmphysemaEpilepsyGall StonesGoitreGonorrheaGoutHay FeverHeart DiseaseHepatitisHerpesInfluenzaKidney DiseaseLeukemiaMalariaMeaslesMiscarriageMononucleosisMumpsParasitesPelvic Inflammatory DiseasePCOSPleurisyPneumoniaProstatitisRheumatic FeverRubellaScarlet FeverSexual abuseStrep ThroatSinusitisStrokeSun StrokeThyroid IssuesTonsilitisTuberculosisWartsWhooping CoughWormsYellow FeverOther
If you checked "Other" above, specify what these are.
Are you still not totally well as a result of any of the previous conditions you have had? If so, please specify which conditions.
Which of the following ailments, or any other major ailments, have affected your relatives?

AlcoholismAllergiesArthritisAsthmaCancerDepressionDiabetesEpilepsyGonorrheaGoutHeart diseaseInsanityParalysisPneumoniaSkin DiseaseSyphilisTuberculosisOther
What major operations have you had?
What major injuries have you had?
Women: Age of first menses:
Women: Number of pregnancies:
How much of the following substances do you use?
Is there any other information that I would need to know?
Medical/Professional Waiver

PLEASE READ THE FOLLOWING CAREFULLY.

IF UNDER 19 YEARS OF AGE, A PARENT OR GUARDIAN MUST SIGN.

I, the undersigned, understand that Lisa Decandia is a homeopath and not a licenced medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions.

In consulting with Lisa Decandia, I am exercising my right to choose an alternative method of treatment through which to address my total health. As Homeopathy is not covered by the existing government medical insurance plan, I agree to pay all fees presented in the current rate schedule.

I agree that "symptoms" from my consultations may be used for homeopathic teaching purposes. I acknowledge that all personal information will be kept confidential.

I consent that from time to time, I may receive emails from Lisa Decandia which will provide me with information about relevant health issues, upcoming events, homeopathic and natural health seminars and learning opportunities. I understand that I can unsubscribe to these emails at any time.

By signing below, you agree to all of the conditions of this waiver.
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Health History Form