Client Forms

These forms are required for new clients who have already scheduled an initial chronic consultation.

Please fill them out at least 24hrs before your scheduled appointment.

Date

Month

Day

Year

First name

Last name

Age

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Occupation

Retired?

Yes

Are you interested in Homeopathy Classes

Yes

Spouse or Partners Name:

Parent's Names (if client is a child):

Children's Names & Ages even if adults (Siblings names if client is a child):

Medications presently taking and what they are for:

What is your chief complaint? Please briefly list the ailment(s).

When did you first have this/these complaint(s), even in a very mild form?

What, if any, diagnosis was made? What diagnostic tests were performed?

Did you consult a health professional? If so, what is their specialty?

Please list any known history of disease in your family such as cancer, heart disease, diabetes, alcoholism, etc. What is your relationship? If deceased, what was your parents', grandparents', siblings' cause of death?

Please list any treatments and/or noteworthy medical events including dental history. Specific dates are not important; approximate as best you can.

Client Signature:

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(Parent/Guardian if child under 21)

I understand when signing this document that Wendy Dickens, PHom, of Wholly Homeopathy, is trained in Practical Homeopathy®. She is not a licensed medical doctor, nor should she take the place of one on my healthcare team. Wendy Dickens does not prescribe, advise, or make any health decisions for me. Her role is that of an educator informing clients of the specialized information that best matches the totality of symptoms as discussed in their case. It is entirely my choice whether to take advantage of the information provided to me.