Adult Intake Form Adult Intake Form Today’s Date: Full Name: Full Address: Main Phone Number: Alternate Phone Number (work/ home): Email Address: * Birth Date: (MM/DD/YY) Gender: Marital Status: Occupation: Employer: Emergency Contact: Relationship to Patient: Emergency Contact Phone Number: Family Doctor Name: Family Doctor Phone Number: Other Healthcare Provider: Name of Homeopath if treated previously: Referred by: If currently under the care of another physician, please explain for what condition you are being treated: Height: Current Weight: Blood Pressure: Pulse: What is your main concern: When did it start? Did your illness start after an event, accident or mental upset, such as shock, worry, dietary, overexertion, weather? Please, explain: What makes it better or worse? Do you have any other health concerns? If so, please list them in order of importance. List any allergies you might have: Do you have any prior conditions after which you never felt totally well again? If so, please, explain: FEMALE CLIENTS: Date of last menstrual period: Age at First Period: Number of Pregnancies: Number of Children: Number of Miscarriages or Abortions: Please, check if you have had or are experiencing any of the following conditions: Abscesses Alcoholism Anemia Appendicitis Arthritis Asthma Cancer Chicken Pox Cold Sores COVID Depression Diabetes Eczema Epilepsy Emphysema Gall stones Goiter Gonorrhea Gout Headaches Heart trouble Hypertension Hepatitis Herpes Influenza Jaundice Kidney Disease Leukemia Liver Disease Malaria Measles Mental Illness Mononucleosis Mumps Nose Bleeds Parasites Pelvic Inflammatory Disease Pneumonia Prostate disease Rheumatic Fever Sexual Abuse Skin disease Strep Throat Sinusitis Stroke Syphilis Tonsilitis Tuberculosis Venereal Warts Warts Whooping cough Worms OtherOther How much of these substances do you use and how often: Tobacco: Coffee: Alcohol: Recreational Drugs: List previous vaccinations and any adverse reactions:_ What physical activity do you do? How often and how much? List any treatments, medicines, supplements, homeopathic remedies you are taking, for how long and their effect on you: Have you lost or gained any weight recently? If so, how much List any major surgeries, date and reason: List any major injuries, date and reason: Family History (what diseases affected your family, these can include:) Alzheimers Alcoholism Asthma Arthritis Cancer Diabetes Depression Epilepsy Gonorrhea: Hypertension Heart Disease: Hepatitis Mental Illness Pneumonia Skin diseases Syphilis Tuberculosis Ulcers OthersOthers Mother Mother's Current age Mother's Age of death Mother's Cause of death Mother's Disease(s) Maternal Grandmother Maternal Grandmother's Current age Maternal Grandmother's Age of death Maternal Grandmother's Cause of death Maternal Grandmother's Disease(s) Maternal Grandfather Maternal Grandfather's Current age Maternal Grandfather's Age of death Maternal Grandfather's Cause of death Maternal Grandfather's Disease(s) Father Father's Current age Father's Age of death Father's Cause of death Father's Disease(s) Paternal Grandmother Paternal Grandmother's Current age Paternal Grandmother's Age of death Paternal Grandmother's Cause of death Paternal Grandmother's Disease(s) Paternal Grandfather Paternal Grandfather's Current age Paternal Grandfather's Age of death Paternal Grandfather's Cause of death Paternal Grandfather's Disease(s) Sister(s) Sister(s) Current age Sister(s) Age of death Sister(s) Cause of death Sister(s) Disease(s) Brother(s) Brother(s) Current age Brother(s) Age of death Brother(s) Cause of death Brother(s) Disease(s) Aunt(s) Aunt(s) Current age Aunt(s) Age of death Aunt(s) Cause of death Aunt(s) Disease(s) Uncle(s) Uncle(s) Current age Uncle(s) Age of death Uncle(s) Cause of death Uncle(s) Disease(s) Children Children Current age Children Age of death Children Cause of death Children Disease(s) Captcha Submit If you are human, leave this field blank. Δ
