Adult Consultation Form

Homeopathy with Cloe Consultation Form

PLEASE FILL IN ALL SECTIONS TRUTHFULLY AND IN DETAIL.
Your Details
Name

First NameLast Name
Birthdate

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province / County

Postal Code / Zip CodeCountry
Best phone number to contact you. Please include your country code.

Country CodeArea CodePhone Number
Your Email address

Confirmation Email

Your current and previous medical history
Please list all your CURRENT medication, vitamins and other supplements that you are taking.
Please list any long-term prescriptions that you are taking or have taken. Examples include; birth control pills, blood pressure tablets, asthma inhalers, tranquilizers,etc.
Please list all vaccinations that you have had and, if applicable, any severe reactions.
Please list all allergies and intolerance that you have or have had.
Please provide details of any other therapies that you are currently undergoing. Examples include; acupuncture, naturopathy, Chinese medicines, psychiatry, psychology, massage, other body therapies.

Your medical history...continued
Please list, by date, if possible, your major diseases, illnesses, accidents, hospitalisations, medical tests.
Please list your childhood illnesess with your approximate age at the time. For example; chickenpox, tonsillitis, mumps
Please list any life traumas that you have experienced. For example; bereavements, job loss, income loss, moving.

Your family medical history
Information about the health of your blood relatives, whether they are still alive or have died, is of value to a Homeopathy treatment plan.

Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Downs Syndrome, behaviourial problems or other conditions.

Please provide the cause of death and the age at time of death, if known.
Your MOTHER'S Side of the Family
Your Mother
Your GrandMother
Your GrandFather
Your Aunts
Your Uncles
Your Cousins

Your family medical history...continued
Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Downs Syndrome, behaviourial problems or other conditions.

Please provide the cause of death and the age at time of death, if known.
Your FATHER'S Side of the Family
Your Father
Your GrandMother
Your GrandFather
Your Aunts
Your Uncles
Your Cousins

Your family medical history...continued
Please give details about any serious diseases, history of alcohol and/or drug addiction, epilepsy, Downs Syndrome, behaviourial problems or other conditions.

Please provide the cause of death and the age at time of death, if known.
Your Sisters (please provide ages)
Your Brothers (please provide ages)
Your Children (please provide ages)

Homeopathy with Cloe Consultation Form