New Client Intake Form, Christina Thevaos Homeopath

New Client Intake Form

Share your health history and details for your homeopathic consultation.
Full Name of Client

First NameLast Name
Preferred Name
Parent/Legal Guardian (if applicable)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Number of children and ages
Email Address
example@example.com
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
What is your occupation? Are you currently doing this? What have you done in the past? Do you enjoy your work?
Please list any allergies or sensitivities. List your reactions to each.
Current Conventional Medications (if any), for what condition you take them, and if you have any side effects.
VACCINATION HISTORY
Current Supplements, Vitamins, Herbals (if any), for what condition you take them, and if you have any side effects.
CHIEF COMPLAINTS: the main things you wish to work on. Include when they began and details about each. Separate them into paragraphs.
Please upload pictures of chief complaints (like skin issues, cysts, tumors, rashes)

Cancelof
Pictures of you. Give me a few pictures of yourself (current) and a few from the past few years.

Cancelof
CAN YOU TRACE THE ORIGIN OF ANY PRESENT CONDITION TO ANY PARTICULARCIRCUMSTANCE? (e.g. accident, illness, grief, mental upset etc.).
ANY SERIOUS SHOCK, GRIEF, DISAPPOINTMENT, FRIGHT, DEPRESSION, ETC.?
HEIGHT, WEIGHT and PHYSICAL BUILD/BODY TYPE
Have you lost/gained any weight lately? How much and why?
Have you previously used homeopathic remedies?
Please describe any previous homeopathic treatments you have tried, it's success/failure and briefly what type of methodology was used (if you worked with a previous homeopath).
Describe your general lifestyle (diet, exercise, pleasure).
STRESS: what are your perceived stresses and how do you feel them in your body? How do your actions reflect that you are stressed?
SLEEP: Good/bad? Restless? How much per night? What position do you sleep in? Anything unusual about your sleep (must be unclothed, get really hot, sleep with feet uncovered, etc)? Do you talk/walk/sit up in your sleep?
DREAMS: recurrent? themes? nightmares?
ENERGY: What is your overall energy level? What times of day are you generally the best (energy, mood, symptoms)?
PERSONAL HEALTH HISTORY: beginning in birth/childhood and moving to the present, please list illnesses you have had (earaches, chicken pox, strep, mono, pms, recurring illnesses, surgeries, hospitalizations, shingles, births/miscarriages, etc). Do your best to list approximate years/ages.
FAMILY HEALTH HISTORY: list diseases in your family including siblings, parents, children, grandparents, aunts/uncles, 1st cousins. Use abbreviations like PGM (paternal grandmother). Include cancers, mental illness, asthma allergies, blood pressure, etc, etc
Upload test results like current bloodwork, MRI, Xrays, etc

Cancelof
Should be Empty: