Registration Form (Confidential)

Fill out , print and bring to consultation.

For Skype consultations, fill out, copy/paste on Word or Pages document and email to ingrid@homeopathe.ca

Name:
If under 18,
Parents names:
Age: Date of birth:
Adress:

Postal code (Zip):
Tel. Home: Cell Phone
Email:
I wish to be part of your mailing list and receive health information and homeopathy tips :
Recommended by:
 

Health conditions in your order of importance
Problem Since Causes
1.
2.
3.
4.
 

What medication are you presently taking?
Medication Since Side Effects?
1.
2.
3.
 

What treatment or Diet are you presently following?
Treatment or Diet Since Results
1.
2.
3.
 

Indicate the year and month if possible, of all illnesses and health troubles you have had in your life. Please write year, if possible.

Abscess Epilepsy Kidney Disorder Sinusitis
Alcoholism Miscarriage Malaria Syphilis
Allergies Yellow fever Menopause Typhoid
Skin Condition Goiter Mononucleosis Tuberculosis
Anemia Gonorrhea Mumps Urethritis
Arthritis Gout Otitis Vaginitis
Asthma Influenza Parasites Small Pox
Bulimia Hepatitis Pleuresy Worms
Gallstone Herpes Pneumonia Warts
Condylomata Genital Herpes Prostatitis Genital Warts
Cough Stroke\Angina Articular. Rheumatism Zona
Depression Throat infection Hay Fever Bronchitis
Diabetes Leukemia Measles Cancer
Emphysema Heart Disease Rubella Tonsilitis
Endometriosis Skin Disease Scarlet fever  
 

Other major illnesses or any you never got over ?
Which operations did you have ? When? Complications?
1.
2.
 
Major injuries? When? Long term effects?
1.
2.
3.
 
List all vaccines received When? Side effects?
1.
2.
3.
 

Have you taken antibiotics repetitively or for a long period?
yes No If yes, When ? What was the cause?
 
 

Any important weight loss or gain?

yes No How much ?
 
 

Which exercises do you do?
Exercises: Frequency:
1.
2.
3.
 

How much of the following substances do you use? Specify per day or week.
Tobacco/Alcohol: Coffe:
Tea: Drugs:
 

Indicate number of:
Pregnancies: Children:
Abortions:    
 

Indicate which of the following affected your relatives:
Alcoholism Depression Heart Disease Syphilis
Allergies Diabetes Skin Disease Mental Problems
Arthritis Epilepsy Paralysis Tuberculosis
Asthma Gonorrhea Pneumonia  
Cancer Gout Hay Fever
 

About Your Family:
Age if living Age of Death Major Illnesses
Mother:
Father:
Sisters:
Brothers:
Children:
Maternal Gd-mother:
Maternal Gd-father:
Maternal Uncles\Aunts:
Paternal Gd-mother:
Paternal Gd-father:
Paternal Uncles\Aunts:
 

When was your last complete medical examination?
 

Are you presently under the care of another doctor or therapist?
Doctor name? For which illnesses? Treatments and Results?
1.
2.
 

Have you ever received a homeopathic treatment?
Homeopath name? For which illnesses? Treatments and Results?
1.
2.

 

Registration Form Part 2

About yourself

Should you type the answers, please use a different colour or font so the answers may be easily distinguished from the questions. Thank you

 

How long have you suffered from your symptoms?
(For each health condition, when did they appear, what year, month, time of the year? )

 

How did your symptoms appear?
(In what circumstances, in what way, which side of your body? Give all details you can remember)

 

Do you notice any particular state of body or mind that appears together with your symptoms? Any change of mood?

 

Any other detail you wish to share about your symptoms?

 

FOOD

What are your food cravings, the food you could not go without? (including spices, salt, ketchup, sugar, healthy or unhealthy , what are your STRONG taste preferences, if any ? )

 

What are our food aversions? Things you can not bear the taste or smell of ?


Any food allergies or intolerances ? Any food or condiments that do not agree with you? (They may cause a stomachache or headache, fatigue...)

 

How is your appetite? (Hour of the day, of the night. Rythms)

 

Any preference for food temperature?


How is your thirst ? (Day, night. Craving or aversions for beverages?)

 

Any preference for temperature ?

 

DIGESTION

How is your digestion?

 

How is your bowel movement? (any recurring particularity or concern about your stool? Too hard, painful, fissures and bleeding, too soft, frequent soft stool or diarrhea ? Any discomfort when passing stool? )

 

Urination? (frequency, any particularity?)

 

MENSTRUAL CYCLE

When did you get your first menstruation? How is/was your cycle? Any PMS? Any pain?

 

CLIMATE

What are your significant reactions to different climates, seasons, sun, wind, rain, dampness, dryness, thunderstorm ? Comfort, discomfort?

 

BODY TEMPERATURE

Are you chilly, hot, do you perspire too easily and profusely ? If so, on which part of your body ? Anything significant and recurring ? If so, what time of the day or night? Comfort, discomfort?

 

 

SLEEP & DREAMS


Anyting recurring or significant about your sleep?
(Including sleep walking or talking, state of mind at night before falling asleep, any ritual to fall asleep, favoutite position, waking up in the middle of the night?)

Do you easily fall asleep ?
What is your state of mind upon going to sleep?

How is the quality of your sleep ?


Do you wake up regularly at night ? If so, under specific stress or circumstances?



Refreshed or not in the morning?

 

Anything else around your sleep that is significant to you?



What are your recurring dreams? (Present or past)
If not recurring, please write dreams that you remember and period of life, if possible.

 

 


EMOTIONS

What makes you happiest ? (thrilled, excited )

 

What are your present recurring fears?

 

As a child,what were your recurring fears?

 

 

Any significantly reccuring emotions? Under what kind of circumstances?
(anger, sadness, frustration, embarassement, disappointment, humiliation, excitement, disappointment, aprehension, anticipation... or else ?)

 

 

What makes you very sad, upset ? (Please give an example)

 

 

What makes you cry? (In your life, or outside your life, things you've been through or things you have seen outside your own life that made you cry ? )

 

 

 

For SKYPE consultations, please copy/paste on a WORD or PAGES document and email to ingrid@homeopathe.ca

 

 

IMPORTANT. PLEASE NOTE

Once your appointement if booked, I need a notice of at least 24 hours for cancellation so your time may be offered to someone else who may need it. Without this 24 hour notice, your appointement will be charged. Paypal payments are nun-refundable if you do not show up for the consultation. Nevertheless, I remain flexible for emergencies.

Please sign here that you have read and accpeted these conditions.

 

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