Adult-Adolescent Homeopathic Intake Form

Health History Form

LDC Wellness - Child Homeopathic Intake Form
Patient's Name*

First NameLast Name
Date of Birth of Patient*
Example: January 1, 2000
Parent 1's Name*

First NameLast Name
Parent 2's Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone Number
Primary Contact Email Address*
example@example.com
Telephone Number of Parent 1*
Telephone Number of Parent 2
Referred by:
Current family doctor and phone number
Major complaints in order of importance:*
Which medications is your child currently taking?
What major operations or injuries has your child had?
Does your child have any food intolerances? If yes, what are they?
Check the conditions that your child has had:

AbscessesAllergiesAnemiaAsthmaChicken PoxCold SoresColicEar InfectionsEczemaFrequent ColdsInfluenzaMeaslesMononucleosisMumpsParasitesPneumoniaRheumatic FeverRubellaScarlet FeverSkin AilmentsStrep ThroatSinusitisSun StrokeTonsilitisThrushTravel SicknessTuberculosisTyphoid FeverWartsWhooping CoughWormsOther
If you checked "Other" above, specify what these are.
Are there any of the preceding conditions after which your child has not been totally well again? If so, please specify which conditions.
Which of the following ailments, or any other major ailments, have affected your child's relatives?

AlcoholismAllergiesArthritisAsthmaCancerDepressionDiabetesEpilepsyGonorrheaGoutHeart diseaseInsanityParalysisPneumoniaSkin DiseaseSyphilisTuberculosisOther

Your child's vaccination history

	Vaccinated
Measles
Mumps
Rubella/German Measles
Chicken Pox
Whooping Cough
Meningitis
Hepatitis B
Tetanus
Haemophilus
Pneumococcal
Meningitis
DPPT

If your child has had any adverse effects from any vaccine, please note which vaccine and what the reaction was.
Natural mother's age at child's birth?
Natural mother's health during your child's pregnancy - list any bleeding, nausea, illness, physical or emotional trauma, hypertension, diabetes, medications, alcoholism, drug use, cigarette use, etc.

About the birth of your child:

	Full Term	Premature	Late
Birth history

Length of labour:
Complications during labour:
Did the child's natural mother have any previous pregnancies, miscarriages or complications?
What was your child's birth weight?
At what age did your child begin to:
Your child's feeding as an infant:
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 child's 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 child's 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, as the parent or guardian of the child being treated, you agree to all of the conditions of this waiver.
Signature of Parent*

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Health History Form