Intake | Holt Homeopathy

Name

Your email*

Date of Birth

Marital Status

Married

Single

Divorced

Widowed

Telephone - Home*

Telephone - Work

Referred by*

Present M.D. and Phone*

Blood Type*

Weight*

Height*

Number of Children*

Number of Pregnancies (women)

Last time you had a fever*

Tick all the vaccinations you have had*

Measles

Mumps

Chicken Pox

Whooping Cough

Pneumonia

Covid

Boosters

Other

For each one ticked, at what age did you get vaccinated and what dates?*

Did you have any reactions? If yes, from which?*

Any other additional vaccinations/shots? If yes, which?*

What are the Major Complaints in Order of Importance For You? (include the date it started and cause)*

Which Medications are you Currently Taking? (Include the date you started taking it, the dose any adverse reaction, if any)*

What Other Treatments or Regimes Are You Currently Taking? Include what you're treating, when you started and any results you have had*

Have you had ANY of the Following Conditions? Tick ALL that Apply*

Abscesses

Alcoholism

Allergies

Amnesia

Anemia

Arthritis

Asthma

Cancer

Chicken Pox

Cold Sores

Colitis

Covid

Depression

Diabetes

Emphysema

Epilepsy

Gall Stones

Goiter

Gonorrhea

Gout

Hay-Fever

Hepatitis

Herpes

Influenza

Kidney Disease

Leukemia

Malaria

Measles

Miscarriage

Mononucleosis

Mumps

Parasites

Pelvic Inflammatory Disease

PCOS

Pleurisy

Pneumonia

Prostatitis

Rheumatic Fever

Rubella

Scarlet Fever

Sexual Abuse

Skin Disease

Strep Throat

Sinusitis

Stroke

Sun-Stroke

Thyroid Issues

Tonsillitis

Warts

Whooping Cough

Worms

Yellow Fever

NONE

Any Other Major Conditions/Concerns?*

Are there any of the preceding conditions after which you have not been totally well again? If yes, which ones?*

(Women)Age of first Menses:*

What major operations have you had? Were there any complications?

Which of the following substances are you using?*

Tobacco

Alcohol

Coffee

Recreational Drugs

Which of the following ailments, or any other major ailments have affected your relatives?*

Alcoholism

Allergies

Arthritis

Asthma

Cancer

Depression

Diabetes

Epilepsy

Gonorrhea

Gout

Heart Problems

Insanity

Paralysis

Pneumonia

Skin Disease

Syphillis

NONE

Please enter any other information that I would need to know about the following relatives: Mother, Father, Brothers, Sisters, Children, Maternal Grandmother, Maternal Grandfather, Paternal Grandmother, Paternal Grandfather, Maternal Aunts, Maternal Uncles, Paternal Aunts, Paternal Uncles. (include age if alive, age at death, any ailments)

Medical/Professional Waiver PLEASE READ THE FOLLOWING CAREFULLY AND TYPE YES BELOW(if under 19 years of age, a parent or guardian must sign.) I, the undersigned, understand that Erica Holt is a homeopath 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 Erica Holt, 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 agree that “symptoms” from my consultations may be used for homeopathic teaching purposes. I acknowledge that all personal information will be kept confidential. I consent that from time to time, I may receive e-mails or text messages from Erica Holt and/or Holt Homeopathy which will provide me with relevant health information/newsletter, upcoming events, homeophatic and natural health seminars and learning opportunities. I understand that I can unsubscribe to these e-mails at any time. *

Patient Signature*

Date*

Short answer

Mailing Address

City, State, Zip

Intake Form

Erica Holt, DCHM