Adult Intake Form — Love Homeopathy

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone: Home

(###)

###

####

Telephone: Work

(###)

###

####

Referred By

Present M.D. & Phone Number

Major Complaints in Order of Importance (since when have they occurred?)

Medications you are currently taking (and any adverse effects)

What Other Treatments or Regimes Are You Currently Following?

Treatment/Regime, since when, and results

Other Major Conditions Not Listed:

Are there any of the preceding conditions after which you have not been totally well again? Which ones?

Age of first Menses

Number of Pregnancies

Are You Currently Under the Care of a Physician(s)?

Physician For What Condition? Treatments

Any Major Operations/Injuries? (Please note when and if there were complications)

What Major Injuries Have You Had?

Injury, when and complications

Vaccination History:

Measles

Yes

Mumps

Yes

Rubella/German Measles

Yes

Chicken Pox

Yes

Whooping Cough

Yes

If YES to any of the above, please list any adverse effects from these vaccinations:

How Much of the Following Substances Are You Using?

Tobacco

Alcohol

Coffee

Recreational Drugs

Relatives

Please list any known ailments for the following relatives

Mother

Father

Brothers

Sisters

Children

Maternal Grandmother

Maternal Grandfather

Maternal Aunts/Uncles

Paternal Grandmother

Paternal Grandfather

Paternal Aunts/Uncles

Is there any other information that I would need to know?

Have you received the Covid-19 Vaccine?

Pfizer

Moderna

Astra Zeneca

Johnson & Johnson

N/A

Mixed

Please provide the dates of each shot & booster

Ie. First Shot January 1st, 2023. Second Shot February 15th, 2023. First Booster March 30th 2023

Medical/Professional Waiver

PLEASE READ THE FOLLOWING CAREFULLY (if under 19 years of age, a parent or guardian must sign.) I, the undersigned, understand that Aimee Marples is a homeopathic practitioner of classical homeopathy and not a licensed medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. In consulting with Aimee Marples, I am exercising my right to choose an alternative method of treatment through which to address my total health. As homeopathy is not covered by the existing government medical insurance plan, I agree to pay all fees presented in the current rate schedule. I acknowledge that all personal information will be kept confidential. In signing below, I confirm that this e-signature is a legally-binding true signature.

Date of Signature

YYYY

Witness Signature

I give permission for Aimee Marples to use this case in teaching and lectures (confidentiality maintained)

Yes

Homeopathic Consultation Form

Aimee Marples, DCHM, HD (RHom)