Adult Intake Form

Adult Intake Form

Share your personal details, medical history, current treatments, and the main reason for your appointment.
Contact
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Birth

Hour Minutes

AM/PM Option
Place of Birth
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact

First NameMiddle NameLast Name
Relationship Status
Gender at Birth
Current Gender
Height
Weight
Current Occupation(s)
Past Occupation(s)
Please let us know if someone referred you
Medical History & Current Care
Current Medications and Supplements
Environmental or Seasonal Allergies and Description of them
Current Therapies
Vaccines / Immunizations Received

Other
Travel Vaccines ?
please list travel vaccines here
Diagnoses, Conditions, and Family History
Diagnosed, suspected, or past conditions

Other
Check if you've ever had any of these conditions in your life:
Are any of the following ailments present in your family history:
Any additional notes on family history
Average sleep hours
Trouble falling asleep
Details about trouble falling asleep
Trouble staying asleep
Details about trouble staying asleep
Main reason(s) for appointment
How long this has been going on
What else was going on when this started?(Ie new medications, loss, moving, illness, trauma, or accident)
What makes it better or worse
Time of day or year it is better or worse
Developmental & Trauma History
Describe yourself as an infant, including any relevant details about your mother’s pregnancy if known
Describe yourself as a child
Please list any small or large traumas you have experienced. Just a brief list, no need to include painful details.
Please list any surgeries
Male Health
Any penile or prostate dysregulation
Sexual desire

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Excessive masturbation
If yes, please provide details
Female Health
Sexual desire

1

2

3

4

5

6

7

8

9

10

1 is Very low, 10 is Very high
Number of pregnancies
Any losses- abortion or miscarriage? How many?
Problems conceiving or during pregnancy
Current cycle frequency and bleed length
Premenstrual mood changes or related symptoms
If yes, please describe mood changes
Menstrual flow details (color, clots, smell)
Strong physical symptoms during periods (Pain, nausea, etc)
What makes symptoms better or worse
Age at first menstruation
Contraceptives used and duration
Perimenopause or menopause experience
Smoking

Other
Smoking details (what, how much, how often)
Substances used

Other
Substance use details (how much and how often)
Digestive issues
Troubling or repeated dreams
Food preferences, cravings, or aversions
Fears
Temperament
What makes you feel most alive and most yourself
Biggest struggles in life
Please list anything else you would like me to know

RETAINER AGREEMENT AND CONSENT TO TREAT
I, ______________________________________________, hereby retain Amber Bees Lombard as a homeopathic consultant.

I understand that she does not seek to diagnose, treat, or prescribe for illness, injury, disease, disorder, or other pathological conditions. Instead, she seeks to stimulate my own defense system with the use of homeopathic remedies so that I can better deal with the wide variety of stresses I experience. In exploring this homeopathic practice, I am interested in monitoring my confrontation with stress and in stimulating my own healing abilities to move through crisis naturally. I have had ample opportunity to discuss the relationship between the treatment of pathology and the employment of the homeopathic approach as practiced by Amber Bees Lombard. I agree to consult a physician for any concern about pathology which may arise during the term of this agreement, and to inform Amber Bees Lombard of such consultation and its results. In choosing this approach, I realize that some of my symptoms of discomfort may get worse before they get better, and I could elect to minimize or eliminate uncomfortable symptoms by obtaining treatment according to accepted standards of medical practice from a physician.
In order to maximize the benefit which I might receive from this work, I agree to:
Consultant, Amber Bees Lombard, agrees to elicit a history of indications relevant to my constitutional disposition, advise me accordingly, and provide me with an opportunity to undertake a homeopathic remedy according to the principles of the empirical science of homeopathy. This agreement shall remain in effect, unless terminated in writing by either party to the other.
Signature
Name

First NameLast Name
Date signed

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