Intake Form

Intake Form

New Moon Homeopathic Clinic
Patient Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Medical Doctor's Name

First NameLast Name
Phone Number
Health History:
What is Your Main Concern?
When Did It Start?
For example: It begun 3 years ago, 3 months ago or date it begun.
Do You Know the Cause?
For example: dietary change, illness, accident, exertion, allergies, shock, weather, etc.
Are you smoking? If yes, how many packs a day?
Please check if you have ever had any of these conditions:*

AbcessessAnemiaAnxietyAppendicitisArthritisAsthmaBone problemsCancerChicken PoxChronic coughCold SoresDepressionDiabetesEczemaEmphysemaEpilepsyGall StonesGonorrhoeaGoitreGoutHeadachesHeart TroubleHepatitisHerpesHips painHypertensionInfluenzaJaundiceKidney DiseaseLeukaemiaLiver DiseaseMaleriaMeaslesMental IllnessMiscarriageMononucleosis (mono)MumpsNose BleedsParasitesPelvic Inflammatory DiseasePneumoniaProstate DiseaseRashesRheumatic FeverSexual AbuseSinusitisSkin DiseaseSprainsStrep ThroatStrokeSyphilisTonsilitisTuberculosisVernereal WartsVision problemWhooping CoughWormsWartsOther
Are you currently taking any medications? If yes, please list them below:
Do you have any medicine allergies?

YesNo
Please list them.
Number of Pregnancies Number of Children
Are you currently pregnant?

YesNo
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
Have you experienced any injuries to any part of your body? If yes, please indicate what body part. Please be specific.
Family History
Please tell us what ailments affected your family. These can include:*

Alzheimer'sAsthmaAlcoholismArthritisCancerDiabetesDepressionEpilepsyGonorrhoeaHypertensionHeart DiseaseHepatitisMental IllnessPneumoniaSkin DiseasesSyphlilisTuberculosisUlcersOther

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

Servies and Fees
Initial Assessment (1.5 - 2 hours):
(consultation not including remedy [$10-$15], a one time fee, unless treatment is restarted after 1.5 years) - $222

Follow-up visit (45-60 minutes):
Children age 10 and under - $75
Adults - $100

* Prices typically held once a month (follow-ups) 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

Remedies will be prescribed after consultation and patients will be guided on how to receive them and dose.

Acute conditions (25-30 minutes):
Acute- Care - $90/ 25-30 minutes

Telephone consultations - $30/15 minutes
Extended Acute- Care - $130/ 4 days after- care

Email updates about your progress are welcome. If there is more information required from you to provide you to provide the best care, beyond email, I [Anica] will request a phone consultation, which will potentially be charged at the normal rate.
Signature of the Patient

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Intake Form

Patient Information

Health History:

Family History

Servies and Fees