Client Health Profile

Client Health Profile

The Health Profile takes time, perhaps more time than you expect, but it matters. It is how your homeopath comes to meet you before you ever sit together, to learn the small things and the large ones that make you who you are. Complete it before your consultation, slowly and honestly, so that when the time comes, nothing is wasted and the conversation can begin where it truly should.
Client Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
Place of Birth
* Parent’s Name if a minor

First NameMiddle NameLast Name
Address/City

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?
Background and Household
Marital Status
Living arrangements - Live with
Pets
What's your highest level education?
Occupation
Work status
Have you served in the military?
Military branch
If yes, when and where did you serve?
When in the military, did you experience any injuries or receive vaccinations of any kind?
Health History and Current Concerns
Are you familiar with or have had any Homeopathic treatments?
Chief Complaint 1
Chief Complaint 2
Chief Complaint 3
Chief Complaint 4
Chief Complaint 5
Chief Complaint 6
Comments about your most important health problems.
Health Issues and Background
List any health issues you would like to work on. For each issue include 1.When it began 2. What was going on in your life when it began, including emotional events 3. Any other details you feel are important
Have you had any major health issues (physical and/or emotional) or surgeries in the past.
Have you had any previous reactions to vaccinations or medications. If so, list the vaccine or medication and explain.
Mental/ Emotional State
How do you feel emotionally on a day-to-day basis? Please detail and include any information on prior events that may have impacted you being in your current state.
How is your sleep? How many hours of sleep do you get on average? How do you feel when you wake?
Injury
Have you ever had a head injury, concussion, or been knocked unconscious? If so, explain with date.
Any ongoing effects from that injury? Include emotional.
Medication, Vitamins, Remedies
Do you have medication, remedy, or supplement sensitivity?
Are you a sensitive person in general?
List your current vitamins, supplements, herbs, and medications
Do you use any type of recreational drugs? List what type and how often.
What homeopathic remedies previously taken or currently being taking. List results from each.
Lifestyle, Digestion, and Elimination
What type of foods do you crave or gravitate to?
What type of drinks do you like to drink?
Are you a thirsty person?
Do you like ice in your drinks?
Do you get diarrhea or are you constipated?
Any difficulties with urinating or kidney-related concerns?
For woman only: On average, how long does your is your period last?
About You
Please briefly describe yourself so I can understand your temperament, values, goals, interests, hobbies, etc. Feel free to add anything else here that you think it is important or relevant including any major life changes.
Write a general timeline of you life (birth-present). Try to correlate what was going on in your life around the time your physical/ emotional issues began.
Consent and Signature
Disclaimer Acknowledgment: The services performed by Christine Darling and/or Redding Homeopathy are at all times restricted to the subject of homeopathic matters intended for the maintenances of the best possible state of vitality and health and do not involve the diagnosing, treatment or prescribing of remedies for disease.
Sign
Date (signature)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Name (if child is under 18 yrs.)

First NameMiddle NameLast Name
Parent/Guardian Signature (if child is under 18 yrs.)
Parent/Guardian Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Client Health Profile

Client Information

Background and Household

Health History and Current Concerns

Health Issues and Background

Mental/ Emotional State

Injury

Medication, Vitamins, Remedies

Lifestyle, Digestion, and Elimination

About You

Consent and Signature