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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