Form | Homeopathy

First name

Last name

Birthday

What are your main health concerns right now?

Previous Medical History - Please list all previous health history including surgeries, medication and recurring illnesses. Include approximate dates/years.

Family Medical History - Please list any chronic illnesses in your family history. E.g Cancer, Diabetes, Heart disease, High Blood Pressure, Alcoholism, Tuberculosis, etc

Food Cravings - Please list any foods that you currently crave, if any

Food Aversions/Aggravations/Allergies - Please list any foods that you are allergic or intolerant to, or just generally do not like

Body Temperature - Please state if you feel you are a warm person/ or if you feel the cold

Perspiration - Do you perspire often? If so, whereabouts on your body?

Medication - Please list all current medication, and any previous medication that you have been on (include years), and all known vaccinations.