Pre Consultation Intake form (Female)

Please fill in the below form prior to consultation,

IN ADDITION: During your first consultation we will be discussing your health history. In preparation for this consultation I encourage you to reflect on your health as its been for you over your life time and from birth. To think back on what health issues and interventions and significant events you have encountered over time and when they occurred. This information will be helpful in understanding what underlies your current state of health.

Name *

First

Last

Address *

Email *

Telephone/mobile number *

Date of Birth *

What is your relationship status? (eg married with 2 kids, widowed, single)

Occupation

What are your hobbies, favorite pass times?

Have you worked with a homeopath before? *

If so when did you last work with a homeopath?

Briefly describe your complaint, what are you seeking help with? *

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 (if any)? Include any significant reactions you may have had if any. ( eg childhood vaccines, travel vaccines, Flu vaccination, TB mantoux and Gardacil/HPV 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.

Have you had any surgeries? If so which and when (if known).

Have you had any significant accidents or injuries? If so which and when (if known)

Please list/ state very briefly up to 3 of the most significant events, traumas or stresses you have experienced in your lifetime (if any)

Has there been any event, (eg trauma, illness, exposure, medical procedure) that has caused you to feel you have not/ never fully recovered from? If so what was the event and when did that occur?

Do you have any strong dietary preferences (eg foods or drinks you avoid or crave often) or health determined dietary restrictions ?

(FEMALE SPECIFIC; Please fill in what is applicable) At what age did you start menstruating/ your periods?

Have you had any pregnancies? If so how many and when?

Has conception/ fertility been an issue for you?

Have you used or are you currently using hormonal contraceptive measures, hormone treatments of any kind (eg morning after pill, replacement; natural or other, IVF) ? And if so; which and when?

If you are Menopausal; when did you experience your last menses/period?

Is there any other female specific information you feel is important for you to mention here?

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