Homeopathy with Nish

Homeopathy with Nish

Intake Form
Full Name

First NameLast Name
Birthdate

MonthDayYear
Date
What is your gender?
Contact Number
Email Address
example@example.com
What is your main reason for seeking Homeopathy?
What outcome are you hoping to achieve?
List the main issues you'd like to focus on
Have you had any recent health tests, please specify
Have you had any other major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or do you suffer from any allergies, chronic or niggling health problems? (please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc.)
Do you suspect your symptoms relate to a particular event or time in your life? ie accident, trauma, illness, dietary change, shock, etc.
Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) nutritional supplements, herbal or homeopathic remedies.
What Vaccinations have you had? Did you have any bad reactions?

Your digestion

	Do you regularly experience…
indigestion (after food or between meals?)
Indigestion after fatty food?
Bowel movement shortly after eating?
Frequent stomach upsets or stomach pain?
Nausea or vomiting?
Pain between the shoulders or under the ribs?
Constipation or hard-to-pass stools?
Diarrhoea or ‘urgency to go’?
Blood or mucus in stools?
Undigested food in stools?
Generally inconsistent bowel movements?
Anal itching?
Thrush or cystitis?
How often do you have a bowel movement?
Have you noticed any recent change in bowel habit?
Are your stools pale, mid brown, dark brown, black, grey?
Have you ever had a stomach upset after foreign travel?
Do any foods cause digestive problems? (which ones?)

Your daily life

	answer
Do you enjoy your daily life?
How many people depend on your support?
Do you feel supported by people around you?
Are you recently separated/divorced/a new parent?
Are you recently bereaved?
Have you moved house or changed jobs recently?
Do you work long or irregular hours?
Is your workload bigger than you can manage?
Are you under significant stress in any other way?
Do you feel guilty when you are relaxing?
Do you have a strong drive for achievement?
Do you often do 2 or 3 tasks simultaneously?
Do you take regular exercise?
Is your job active?
Do you have any active hobbies?
Do you sleep well?
What do you do for relaxation?

Your energy levels

	answer
Do you need more than 8 hours sleep per night?
Is your energy less than you want it to be?
Do you find it difficult to get going in the morning?
Do you feel drowsy during the day?
What time(s) of day is your energy lowest?
What time(s) of day is your energy highest?
Do you get dizzy or irritable if you don’t eat often?
Do you use caffeine, sugar or nicotine to keep going?
Do you find it difficult to concentrate?
Do you feel dizzy or light-headed if you stand up quickly?

Eating habits

	answer
Are you allergic to any foods?
Do you suspect any foods don’t agree with you?
Do you eat on the move/when stressed?
Do you ever have eating binges?
What do you binge on?
Have you ever suffered from an eating disorder?
Are you excessively thirsty?

Women only

	answer
Are you pregnant? If so, how many weeks?
Are you trying to become pregnant?
Are you breast-feeding at present?
How many children have you had?
Have you had problems with fertility?
Have you ever had a miscarriage?
What contraception do you use?
Are you still menstruating?
Are you or have you been on HRT?
Are your periods regular?
Any bleeding or spotting in between?
Are your periods particularly heavy or painful?
Do you suffer from PCOS, fibroids, endometriosis?
Any known genito-urinary conditions?
Are you happy with your sex drive?

Men only

	answer
Do you experience mood swings or depression?
Loss of sex drive?
Loss of motivation and drive?
Any known genito-urinary conditions?
Fertility problems?
Problems achieving or maintaining an erection?
Frequent or difficult urination?
Prostate problems
Wake at night to urinate
Difficult to start or stop urine stream
Pain or burning when urinating

Check the conditions that apply to you:

AbortionAbscessesAlcoholismAllergiesAnemiaAnxietyAppendicitisArthritisAsthmaCancerCardiac DiseaseCardiovascular DisordersChest PainChicken PoxCold SoresDepressionDiabetesEczemaEndometriosisEpilepsyGall StonesGastrointestinal DisordersGenitourinary DisordersGoitreGonorrhoeaGoutHay FeverHematological ConditionsHepatitisHerpesHypertensionInfluenzaJaundiceKidney DiseaseLeukemiaLiver DiseaseLymphatic ConditionsMalariaMeaslesMiscarriageMononucleosisMumpsMusculoskeletal IssuesNeurological ConditionsNosebleedsParasitesPelvic Inflammatory DiseasePoly Cystic Ovarian SyndromeProstate DiseasePsoriasisPsychiatric ConditionsPneumoniaRespiratory IssuesRheumatic FeverSexual AbuseSinusitisSkin DiseaseStrep ThroatStrokeSyphilisThyroid ProblemsTuberculosisUrticariaWartsWeight GainWeight LossWhooping CoughWormsYellow FeverOther
Are any of the following ailments present in your family history:

AsthmaAlcoholismArthritisCancerCardiac diseaseDiabetesDepressionEpilepsyMental IllnessGonorrhoeaPneumoniaHypertensionSkin DiseaseSyphilisTuberculosisOther

What is your Doctor’s Name, Address, Phone
Are any other therapists/clinics involved in your care? Please list:
About the consult:

During your consultation, I’ll ask you various questions about different aspects of your life. I will ask you about your family history, your childhood and even your food cravings. We may also touch on your peak or low energy times of the day, and so on. Don’t feel alarmed; there’s a reason for this thorough approach.
Homeopathy is gentle and subtle. In some cases, a remedy can work within minutes, especially for acute cases. However, in other instances, it may take some time.
It’s also important to note that in some cases, old symptoms may resurface. This could be a rash from when you were five, for example. Don’t panic; this is a positive sign.

I’m excited to work with you!
Read the following and sign bellow to agree:

I have disclosed all the relevant information applicable to this consultation and my health status at this point in time. I consent for the information provided to be used by my Therapist and for my therapist to liaise with appropriate health professionals.

I understand this is a student clinic and that my homeopath will be advising with her clinic supervisor about my case.

Homeopathic treatment is not a substitute for emergency medical care. In case of a medical emergency, I understand I should seek immediate assistance from conventional healthcare providers or emergency services.

I understand all information disclosed is confidential and may not be revealed to anyone without written permission, except when disclosure is required by law.

I understand that only necessary information is collected and the storage, retention, and distruction of your personal information complies with the esisting legislation and privacy protection protocols.

I understand payment is due upon time services are provided unless other arangements have been made prior to the appointment.

I understant payment for Initial Intake is $115 and Follow ups are $85. I will confirm with my homeopath on how to send payment.
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