Get Homeopathic Intake Form 2020-2025

Filling out the Homeopathic Intake Form online is an essential step in your journey toward personalized healthcare. This guide will walk you through each section of the form, ensuring that you provide complete and accurate information for the best possible outcomes.

Follow the steps to successfully complete your online form.

1. Click ‘Get Form’ button to obtain the form and open it in your online document editor.
2. Begin with patient information. Enter your last name, first name, and select your preferred title (Mr., Mrs., Miss, Ms.). Include your marital status, date of birth, age, email address, and street address. Make sure to provide contact numbers — both home and mobile.
3. Answer the question regarding the number of children you have and input your city, province, and postal code. Additionally, indicate your occupation and the name of your employer, including your work phone number.
4. Fill in how you were referred to the service by checking the appropriate box. You may also provide the name and phone number of your family physician, along with details of a previous homeopath if applicable.
5. In case of emergency, provide the name and contact number of a trusted emergency contact person.
6. Record your height and weight for vital statistics. Additionally, document your main health concern, including when it started, and whether it was preceded by any significant life events.
7. List any other health concerns in order of importance and their onset dates. Use the checklist provided to indicate past medical conditions you have experienced.
8. Indicate your use of substances such as tobacco, alcohol, coffee, and recreational drugs. Specify frequency for each.
9. Detail your vaccinations, any reactions you experienced, and describe your exercise routine, specifying the frequency and type.
10. Provide information about any ongoing treatments, medications, supplements, or homeopathic remedies you are using, including the duration and effects on your health.
11. List any major surgeries and injuries you have encountered, and note any complications or long-term effects from these experiences.
12. Outline your family history, noting any familial ailments and their relevance to your own health profile.
13. Complete the systems review section by marking any current or past disorders as instructed.
14. Once you finish filling out the form, make sure to save your changes. You will have options to download, print, or share the form if needed.

Start completing your Homeopathic Intake Form online today to take a proactive step towards your health.