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Online Consultation

Condition for which you are seeking homeopathic treatment (please list all issues you would like to address, we will address these and more during your appointment):

Fetal / Birth/ Young Life Information

Please state (if known) the health of your mother when she was pregnant with you: Did your mother suffer from

Regarding your birth:
At which ages did you develop:
Illness History

If you have been affected by any of the following, please indicate approximately what age you were, and if it was severe orlong-lasting.

Have you suffered from recurring:
Check all boxes that describe the symptoms/ pain:

Family Health History

Indicate in the following chart which ailments have affected your relatives- including their ages- to the best of your ability.

Feel free to ask your practitioner or receptionist for more paper if needed.

Possible ailments include, but are not limited to: AIDS/HIV, alcoholism, allergies (food, environmental, medications), arthritis/rheumatism, asthma, cancer, diabetes, epilepsy, frequent colds, gonorrhea, gout, hay fever, heart problems (high blood pressure, angina, strokes, etc.), Hepatitis A/B/C, hernia, herpes (oral, genital), hysteria, jaundice, lung disease, mental illness (including suicides), obesity, paralysis, pleurisy, pneumonia, skin problems (eczema, psoriasis), thyroid problems, tuberculosis, ulcers, warts (skin, genital), other venereal diseases (syphilis, gonorrhea, chlamydia, etc), and any other issues you know of.

*Please indicate if you have also had any of these conditions, even if they have been treated/ resolved.

Age if alive
Age at passing
Maternal Grandmother
Maternal Grandfather
Maternal Aunts/ Uncles
Paternal Grandmother
Paternal Grandfather
Paternal Aunts/ Uncles

Significant Life Events:

This portion is optional, complete only if you would like to.

Traumatic events can impact your health. Discussing them can often be difficult. It is not necessary for us to discuss the details of these events. However, it is very helpful to know what the effects of the events were, how they left you feeling after the event, etc. If you would rather, we can review this in person.

If you are able, please complete a timeline from birth to present. Situations such as: traumas of your mother during pregnancy with you, romantic disappointments, divorces, work issues, family issues, death of loved ones, humiliations/embarrassments, and other events that have impacted you. Please include on this timeline dates of major illness and onset of physical or emotional issues, including conditions that were treated with suppressive medications.

Include positive events such as marriages and birth of children. Use a separate sheet, other side of a page, or the end of this form.

Explain your:-

a. Reaction during anger; If expressed explain how