Homeopathy Case History Form

Return	Confidential Homeopathy Patient Case History Form
When complete, please print this form and bring it with you to your first appointment.

Patient Information
First Name	Last Name
Street Address	Apartment
Town/City	Province	Postal Code
Home Phone	Work Phone	E-Mail

Birth Date

Age

Sex

Where did you first hear about the clinic? (please be specific)

Medical History

Please describe any major trauma including grief, accidents, surgery, etc. that you feel have effected your life in a significant manner:
Incident	Age Of Occurance

Please list any medication that you are presently taking and the length of time you have been taking them. Please include birth control pills if that is relevant to you:
Medication	Length of time taken

Family Health History

Please try to fill in the following information as accurately as possible:
Relationship	Current Age	Cause Of Death	Ailments
Mother
Father
Sisters
Brothers
Children
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunrs/Uncles
Paternal Aunrs/Uncles

Please check all of the following conditions that apply to your family:
Alcoholism Allergies Arthritis Cancer	Paralysis Pneumonia Skin Disease Syphilis	Depression Gout Hay Fever Heart Disease	Tuberculosis Diabetes Epilepsy Gonorrhea

Please check all of the following conditions that YOU have experienced:
Abscesses Alcoholism Anemia Arthritis Asthma Cancer Colitis Chicken pox Cold sores Depression Diabetes Emphysema Epilepsy	Gallstones Goiter Gonorrhea Gout Hay fever Heart disease Hepatitis Herpes genitalia Influenza Kidney disease Leukemia Malaria Measles	Miscarriage Mononucleosis Mumps Parasites Pleurisy Pneumonia Prostatis Rheumatic fever Rubella Scarlet fever Sexual abuse Skin disease Strep throat	Sinusitis Stroke Syphilis Tonsillitis Tuberculosis Typhoid fever Venereal warts Warts Whooping Cough Worms Yeast infections Yellow fever

Why are you seeking homeopathic treatment?

Date
Signature of Patient / Guardian

Please complete this form prior to arriving at our office. If you have any questions, please do not hesitate to contact our office at 905-898-8098, or wait until your appointment time.