Adult-Adolescent Homeopathic Intake Form

Health History Form

LDC Wellness - BIE Initial Consultant 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 abuseSkin DiseaseStrep 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.
What major operations have you had?
What major injuries have you had?
Female: Age of first menses:
Female: Number of pregnancies:
Female: Any miscarriages or abortions?
Female: Have you used birth control and if so, what type?
Female: Menopause start date
Female: Lingering menopausal complaints
Male: Any history of impotence, or prostate or urination problems? Please specify, and what related treatments you have had.
How much of the following substances do you use?
Which of the following trigger (or cause) symptoms? Check all that apply.

GrassLeavesPerfumesInsecticidesSmokeCold AirHayCatsCosmeticsOdorsPollutionHumidityMold/MildewDogsAerosol SprayDraftsExerciseWeather ChangeBasementsHorsesAlcoholHouse DustNervousnessLatexOther
If you checked "Other", please specify what things cause symptoms.
When are your symptoms worse? Note below if they occur in any specific months and/or if they occur year-round.

Environmental Survey, part 1*

	House	Apt./Duplex	Condo/Townhome
Do you live in a:

Environmental Survey, part 2*

	In the city	In the suburbs	In a rural area
Do you live:

Environmental Survey, part 3

	How many?	What kinds of pets?	In a rural area
If you have pets:

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 Registered Homeopath and Bioenergetic (BIE) practitioner and not a licensed medical doctor.

As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions from a licensed medical doctor.

In consulting with Lisa Decandia, I am exercising my right to choose an alternative method of treatment through which to address my total health and I reserve the right to terminate BIE treatment at any time if so inclined.

I acknowledge that Lisa Decandia does not diagnose or give direction on any current medications or diagnosis treatment plan from my licensed medical doctor.

I acknowledge that the GSR-120 unit used in BIE treatment is not intended to be used to diagnose, cure, prognosticate, or for the treatment of disease or any act which will constitute the practice of medicine in this country in which a medical license is required.

The GSR-120 unit is used to direct energy directly into various acupuncture points on the body to help create homeostasis.

As BIE treatment is not covered by the existing government medical insurance plan, I agree to pay all fees presented in the current rate schedule.

I consent that from time to time I may receive e-mails from Lisa Decandia which will provide me with relevant health information/newsletter, upcoming events, homeopathic, BIE and natural health seminars and learning opportunities. I understand that I can unsubscribe to these e-mails at any time.

By signing below, you agree to the conditions of this waiver.
Patient signature (or parent/guardian)*

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Health History Form