EmailMe Form - Sakota Homeopathy Personal Intake Form

Date Time

MM / DD / YYYY

Name

First Last

Email

Age & Birthdate

Sex

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Employer, Occupation- Full Time or Part Time

Weight & Height

Married, Single, Children

Goals: Please define the goals that you are hoping to achieve by working with me?

Symptom Qualifications: List any significant illness in your family or of which you are a carrier?

Present Symptoms: Please write down, in detail, all of the symptoms / complaints, which you have presently?

Pertinent Negatives: List any drug reactions, food allergies, or any other allergies you may have?

Past Diseases: List all serious illnesses (e.g. hepatitis, glandular liver, malaria) you suffered in the past?

Present Treatment: List all Medicines(drugs, hormones, herbs, vitamins, minerals) you are currently taking?

Surgery: List all serious operations you have undergone?

Accidents: List serious accidents in which you were involved where you suffered serious bodily injury?

Pathological Tests: List any test results, cholesterol, thyroid, uric acid, etc.?

Blood Type / Blood Pressure: What blood type are you? Do you have high / low blood pressure?

Mental / Emotional: Do you experience moments of anxiety or panic? Mood swings, depression, PMS/PMT?

Female: If female, do you have any problems with menstruation, ovarian cysts, fibrosis, and vaginal discharge. thrush? Do you suffer period pain, lose clots, or fluid in breasts, belly, etc. just before or prior to your period?

Male: If male, do you have any problems with prostate gland or stesticles, any sexual dysfunction, low libido / erection? Difficulty urinating, with flow reduced?

Bowels: Do you have regular (daily) bowel movements? Constipation? Loose or diarrhea? Stomach acid? Do you pass a lot of gas? Become bloated with gas? Do you suffer from hemorrhoids?

Digestion: Do you suffer from heartburn or indigestion (reflux), flatulence (gas), or bloating? Do you often crave carbohydrates? Do you feel better after you eat or if you don't eat at all? Do fatty foods, rich foods, chocolates disagree with you? Heavy feeling after eating?

Urination: Do you have any problems with passing urine (frequency, burning, high color / smell, and slow / weak flow? Ever feel burin gin or irritation?

Concentration / Motivation: Do you find it hard to sustain concentration for any time, or is you memory poor? Do you find it have to motivate yourself or sustain motivation?

Head: Are you prone to headaches, migraines? Frequency, severity? Tight band around your head? Does your head ever feel fuzzy?

Sleep: Do you have problems sleeping, difficulty falling asleep, or waking up frequently and lying awake? Do you wake up feeling tired? Do you suffer heart palpitation or hot flashes when you lay down to fall asleep?

Chest: Are you prone to chest complaints like bronchitis, pneumonia, asthma, chest colds, or coughs? Do you catch colds, chest infections?

Spine & Joints: Do you suffer back / neck aches, shoulder tension / spasms, lumbago/ fibrosis's? Do you ever wake in the morning with painful, swollen, inflamed joints? Pins and needles in arms or hands?

Sinuses: Do you have any sinuses problems? Congestion, pressure/ aches, sinusitis? Clear, white, yellow, green? Sinus headaches?

Nose: Do you suffer hay fever, catarrh, rhinitis, postnasal drip or any other nasal drip?

Tongue & Throat: Is your tongue clean? If coated, note color? Is your tongue fissured or grooved or indented by your teeth?

Mouth & Teeth: Are your teeth sound? Do you have fillings, bridges, plates, crowns, root treated teeth, dentures? Dry mouth? Suffer from frequent mouth ulcers?

Skin: Is your skin normal / oily, dry? Do you have a skin disease, psoriasis, eczema, rashes, acne, etc? Does your jewelry change your skin color?

Hair: Is your hair normal, oily, dry? Excessive hair loss? Do you color your hair? Suffer from Dandruff? Scalp gets oily? Do you have split ends?

Nails: Are your nails strong, weak, brittle, ridged, white marks, etc. Do you bite your nails? Do you have nail fungus?

Eyes: Do you wear corrective glasses, lenses? Please list any eye issue or condition? Are you over sensitive to bright light? Do you have blurred vision, cataracts, and painful eyes?

Ears: Do you have hearing problems? Frequent ear infections? Balance disturbances, etc?

Muscle & Nerve: Do you suffer from sharp shooting pains in the head, neck, face, limbs, or twitching in the face of eye muscles?

Cigarettes & Alcohol: Do you smoke? Do you drink queenly?