Pre Consultation Data Sheet

Please fill in the below form prior to consultation to assist with accurate data collection.

IN ADDITION: During your first consultation we will be discussing your health history. In preparation for this consultation I ask new clients to think back on what health issues and interventions and significant events they have encountered over their life time and when they occurred. Also what kind of medications, vaccinations and chemicals they may have been exposed to in the past, that could be significant. This is helpful information in understanding what underlies their current state of health.

Name *

First

Last

(Please fill in any details not already provided) Address

Email *

Confirm Email

Telephone/mobile number

Date of Birth

Occupation *

Briefly describe your complaint *

What are you hoping to achieve with consulting with me/ using homeopathy? *

Details of Health professionals you are currently working with (e.g. GP, Specialist, natural therapist) *

List medications you are using now or regularly use (incl. prescription, over the counter and contraceptive if applicable) *

List any natural health products, supplements and vitamins you use regularly or now.

List any vaccinations you may have received in your lifetime? Include any significant reactions you may have had if any. ( eg childhood vaccines, travel vaccines, Flu vaccination, TB mantoux and Gardacil or Covid vaccines) *

Are you aware of any significant/ long term exposures to environmental, agricultural, industrial toxins you may have had? If so please indicate. *

Please list very briefly up to 3 of the most significant events, traumas or stresses you have experienced in your lifetime.

Briefly list any serious illnesses or trends in your family health history, including cause of death if they have occurred ( incl. parents, grandparents) *

How did you hear about Esther's Homeopathy Clinic? *

I have read and agree with the terms and conditions and Disclaimer *

You can find the Terms and conditions in the menu at the top of this page.

I agree to Esther's Homeopathy Clinic collecting and holding my information secure for the sole purpose of consultation, assessment and communication with me regarding support and prescription. *

I agree to Esther's Homeopathy Clinic adding my email address to her mailing list in order for me to stay up to date with quarterly newsletters, occasional offers and announcements.

Yes please
No thank you