Remedial Homeopathic Clinic

Remedial Homeopathic Clinic

Patient Intake Form
The information contained herein is strictly confidential. Please fill out the form completely and to the best of your knowledge. Even the smallest details are important.
* Required Fields
Date*

DayMonthYear
Title

Mr.Mrs.MissMs.ChildInfant
Name

First NameLast Name
Sex *

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Birth Date*

DayMonthYear
Marital Status

SingleMarried / Common-Law PartnerDivorced / SeparatedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Emergency contact name & relationship*
Emergency contact number*
Family physician name*
Physician contact number
Main Health Concern*
Height and weight
B.P and Pulse
Level of intensity:

0 (None)12345678910 (Worst)
Frequency of occurrence

ConstantIntermittentUnknownOnly under specific condition
Type of medication if any?

AllopathicHomeopathicOther, please specify
Reason and details of current medications if any?
Please check if you ever had or have any of the below conditions

Ance / PimplesAcid RefluxADD / ADHDAlziemerAnemiaAnxietyAppendicitisArthiritisAsthmaAutoimmune DiseaseBackacheBad BreathBody OdorBronchitisCancerConstipationCrampsDepressionDiabetesEczemaEpilepsyFemale DisordersGall StonesGastristisGERDGoutHaemorrhoidsHeart TroubleHigh CholestrolHepatitisHypertensionInsomniaKidney DiseaseKidney StonesMale DisordersMigraineParalysisParkinson'sSciaticaSinusitisSkin DiseaseStrokeTonsilitisThyroidVertigoOtherNone
Urination

Bed WettingBurningDivided StreamFeeble StreamFrequentPainfulLittleExcessiveNormal
Bowel Movement

DifficultHardIrregularUnsatisfactoryNormal
Under what conditions you feel better or worse? For example: Walking makes it better or worse.*
Any other important information
Family History
How did you find us?

PatientWebsiteAdvertisementReferralOthers
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