Medical Intake form

Name

First NameLast Name

Person Filling Out This Form (if not the Patient)

First NameLast Name

Relationship to the Patient

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Place of Birth

City/State or Town/Country if not in the US

Gender

Marital Status

What is the main reason(s) you have booked this consultation? Please put details below including when this issue started and any known triggers.

YesNoUnknown

Were there any adverse reactions to any of the vaccinations they have received?

Rows	No	Yes	Unknown
Hepatitis B (Birth) H-B-VAX II OR ENGERIX B (IM) 1983 onwards
Diphtheria, tetanus, pertussis, hepatitis B, polio, Haemophilus influenzae type b (six weeks) INFANRIX HEXA (IM) OR VAXELIS (IM)
Pneumococcal (six weeks) PREVENAR 13 (IM) 1982 onwards
Rotavirus (oral - six weeks) ROTARIX (Oral)
Meningococcal B (Aboriginal# children only - six weeks) BEXSERO (IM)
Diphtheria, tetanus, pertussis, hepatitis B, polio, Haemophilus influenzae type b (four months) INFANRIX HEXA (IM) OR VAXELIS (IM)
Pneumococcal (four months) PREVENAR 13 (IM) 1982 onwards
Rotavirus (four months) ROTARIX (Oral)
Meningococcal B (Aboriginal# children only) BEXSERO (IM)
Diphtheria, tetanus, pertussis, hepatitis B, polio, Haemophilus influenzae type b (6 months) INFANRIX HEXA (IM) OR VAXELIS (IM)
Meningococcal ACWY (12 months) NIMENRIX (IM)
Pneumococcal (12 months) PREVENAR 13 (IM) 1982 onwards
Measles, mumps, rubella (12 Months) MMR II OR PRIORIX (IM or SC)
Meningococcal B (12 months - Aboriginal children only) BEXSERO (IM)
Diphtheria, tetanus, pertussis (18 months) INFANRIX OR TRIPACEL (IM)
Measles, mumps, rubella, varicella (18 months) PRIORIX TETRA OR PROQUAD (IM or SC)
Haemophilus influenzae type b (18 months) ACT-HIB (IM or SC)
Diphtheria, tetanus, pertussis, polio (4 years) INFANRIX-IPV OR QUADRACEL (IM)
Diphtheria, tetanus, pertussis (Year 7) BOOSTRIX OR ADACEL (IM)
Human papillomavirus (Year 7) GARDASIL 9 (IM)
Tetanus (TdaP)
Influenza (Flu)
Covid
(Prior to 1984 only) Bacillus Calmette–Guérin (BCG) vaccine school program for tuberculosis

Please detail any adverse reactions below.

YesNo

If yes, please list.

YesNo

If yes, please check all that apply

Rows	No	Yes
HIV/AIDS
Gonorrhea
Chlamydia
Oral Herpes
Yeast Infection
Syphilis

Family History - To your knowledge, have any of your blood relatives had any of the following section?

Rows	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease

Please list any surgeries or major illness you have had in the past.

Please list any significant physical trauma you've experienced

Please list emotional trauma you've experienced in your life

Current Medications

Supplements

What type of foods do you crave?

What type of foods do you have an aversion to?

What type of weather do you prefer?

Please describe yourself: Would you (or others)n consider yourself outgoing, shy, friendly, assertive, tidy, messy, intelligent, absent minded, creative, earthy, pedantic, easy-going, moody, funny etc.

Have you received homeopathic treatment before?

If so, what remedies have you had in the past that have helped and what was it prescribed for?

Thank you so much for taking the time to complete this form. I look foreward to seeing you in clinic.

kELLY RYAN HOMEOPATH

Vaccinations

Allergies

Sexual Health

Medical History