Registration Form (Confidential)

Name:
If under 18, Parents names:
Age:			Date of birth:
Adress:
Postal code (Zip):
Tel. Home:				Tel. Office:
Email:
I wish to be part of your mailing list to receive health information and homeopathy tips:
Recommended by:
Reasons to consult 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 last year of all illnesses you have had
Abscess		Epilepsy		Kidney Disorder		Sinusitis
Alcoholism		Miscarriage		Malaria		Syphilis
Allergies		Yellow fever		Menopause		Typhoid
Amydalite		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
Whooping 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 ove?
Which operations have you had?				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
Your Family:
Age if living?				Age of Death?		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.
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