New Client Intake Form, Christina Thevaos Homeopath

New Client Intake Form for Christina Thevaos, Homeopath

Share your health history and details for your homeopathic consultation. If you need to pause and restart, scroll to the bottom of the page and hit the SAVE button.
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
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)

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

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CAN YOU TRACE THE ORIGIN OF ANY PRESENT CONDITION TO ANY PARTICULAR CIRCUMSTANCE? (e.g. accident, illness, grief, mental upset etc.).
ANY SERIOUS SHOCK, GRIEF, DISAPPOINTMENT, FRIGHT, DEPRESSION, ETC.?
Number of children and ages. Please list if living or deceased.
For Women, talk about your pregnancies (all), births and recoveries. Give dates/years. Details appreciated
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

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Is there anything else you’d like to share at this point with me that is relevant to your case - for example, if could be emotional, mental/neurological, family related, weird symptoms, strange rare or peculiar facts about you/ person to be treated…
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New Client Intake Form for Christina Thevaos, Homeopath