Osmium homeopathics, inc



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tarix02.03.2018
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Confidential Patient History--Adult
Name________________________________________Date___________________

Address_____________________________________________________________

Town/City__________________________State__________ Zip_________________

Home Phone_______________________Work Phone________________________

Cell Phone_________________________E-mail_____________________________

Age______________Sex__________Date of Birth________________________

Never Married___Now Married___Divorced___Widowed___Lives with Partner___Other______

Children--names/ages___________________________________________________

Referred by__________________________________________________________

Current Medical Doctor____________________________­­­_____________________

Other Healthcare Providers______________________________________________

Have you ever seen a Homeopath before? ______ yes _______no



Person to contact in case of emergency__________________________________

Relation to client ______________Address________________________________

Phone (h)________________________ (w)________________________

Do you or have you in the past used:

Yes No Past Amount Yes No Past Amount

Coffee ___ ___ ___ ______Sedatives ___ ___ ___ ______

Tobacco ___ ___ ___ ______Thyroid Meds ___ ___ ___ ______ Alcohol ___ ___ ___ ______Laxatives ___ ___ ___ ______ Aspirin ___ ___ ___ ______Cortisone ___ ___ ___ ______

Recreational Birth control

drugs ___ ___ ___ ______ pills (women) ____ ___ ___ ______

Camphor ___ ___ ___ ______ Hormones ___ ___ ___ ______ Steroids ___ ___ ___ ______Vitamins____________________________

Medicinal herbs_______________________ ____________________________

History of hospitalization, surgery or illness: (Please include dates)

_______________________________________________________________________________________________________________________________________________________________________________________________________________



Current Medication:

__________________________________________________________________________________________________________________________________________



Health concerns: ___________________________________________________________________________________________________________________________________________
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