Intake FormsHomeopathy Healings - Abby Beale CCH RSHom(NA)homeopathyhealings@gmail.com413-426-1024PLEASE NOTE: ALL INFORMATION IS STRICTLY CONFIDENTIAL.Welcome to my practice! Thank you in advance for your thoughtful completion of this important information about you. Please complete as much as you can and return before your appointment. If meeting in person, you can bring it with you. Should you need to reschedule your visit or phone consultation, please contact me at minimum of one full business day in advance, to avoid the full office visit or phone consultation fee. Name:DateAddress:City:State:Zip:Cell Phone:Email:Age:Date of Birth:Occupation:Referred byIn case of emergency notify:Phone:Please click the Save and Return button to complete the form later. You will be given a link sent to your email where you can return to complete the form.Save & ResumePlease list the main health problems you’d like help with, in order of importance.Please check if YOU EVER have had ANY of the following. AIDS Allergies Anemia Arthritis Asthma Blood transfusions Bone disease Bronchitis Bursitis Cancer or tumor Chicken pox Colon/bowel disease Diabetes Diphtheria Drug habit Drug sensitivity or reaction Emphysema Emotional or mental problems Gall stones / Gall bladder problems German measles Heart murmur Heart trouble Hemorrhoids Hepatitis/jaundice Herpes High blood pressure Hives Kidney or bladder infection Kidney stones Low blood pressure Lupus Malaria Measles Mononucleosis Mumps Pancreatitis Pleurisy Pneumonia Polio Pancreatitis Rheumatic fever Scarlet fever Small pox Spinal meningitis Tendonitis Thyroid or goiter trouble Tuberculosis Urinary Tract Infection Varicose veins Venereal Disease Whooping cough Yeast InfectionsSelf-Care RitualsFeel free to elaborate after each. Good Sleep: Aerobic Exercise: Stretching: Mindfulness/Stress Reduction Practices: Healthy Eating: Adequate Hydration: Other:Please click the Save and Return button to complete the form later. You will be given a link sent to your email where you can return to complete the form.Save & ResumeSymptomsPlease MARK those symptoms you have ever experienced AND/OR are typical for you. General Chills Acute sense of smell Tend to be Chilly Fevers Fatigue Tend to be warm Sweat easily Thirst for cold drinks Night sweats Thirst for ice cold drinks Bleed or bruise easily Thirst for warm drinksPersonal Notes for GeneralsCardiovascular High Blood Pressure Swelling of hands Low Blood Pressure Swelling of feet Chest discomfort / pain Blood clots Heart palpitations Fainting Cold hands or feet Difficulty breathingPersonal Notes for CardiovascularHead, Eyes, Ears, Nose and Throat Dizziness Night blindness Discharge from eyes Nose bleeds Recurrent sore throat Migraines Blurry vision Poor hearing Sinus congestion Hoarseness Headaches Eye pain Ringing in ears Grinding teeth Sores on lips or tongue Visual Aura Before Headache Eye strain Earaches/ Ear Infections Jaw clicking Facial Pain Excessive tearing Discharge from ear ConcussionsPersonal Notes for Head, Eyes, Ears, Nose and ThroatGenital-Urinary Pain when urinating Leak urine/Dribbling Urgency to urinate Kidney stones Frequency of urination Impotency Blood in urine Change in sex drive Decrease in flow Sores on genitals/HerpesPersonal Notes for Genital-UrinaryRespiratory Cough Coughing blood Asthma / wheezing Pneumonia Pain with a deep breath Bronchitis Difficulty breathing when lying down Production of phlegmPersonal Notes for RespiratoryGastrointestinal Bad breath Indigestion Abdominal pain or cramps Nausea Diarrhea Gas Vomiting Constipation Rectal pain Heartburn Blood in stools Hemorrhoids Belching Black stoolsPersonal Notes for GastrointestinalMusculoskeletal Neck pain Hip pain Shoulder pain Knee pain Back pain Foot/ankle pain Elbow pain Muscle pain Hand / wrist pain Muscle weaknessPersonal Notes for MusculoskeletalNeuro-Psychological Seizures Bad temper Stress Suicidal ideation Areas of numbness Loss of control / violence potential Loss of balance Weakness Vertigo Poor memory Sleep disorder Lack of coordination Anxiety Concussion Depression Substance abusePersonal Notes for Neuro-PsychologicalSkin and Hair Rashes Moles Itching Warts Hives Dandruff Eczema Excessive loss of hair AcnePersonal Notes for Skin and HairPlease list your most frequent childhood illnesses and usual treatmentPlease click the Save and Return button to complete the form later. You will be given a link sent to your email where you can return to complete the form.Save & ResumeVaccinations (check any that apply). Covid-19 and booster(s) Measles, mumps, rubella (MMR) Shingles Tetanus booster SmallpoxOther Flu vaccine Pneumonia vaccine Polio Chicken pox/varicella Diphtheria/pertussis/tetanus (DPT) HPV-2 or 3 shot seriesPlease list all current medicines and supplementsFamily history (grandparents, parents, siblings) - check any that apply and list family member(s) in the blank. Cancer: High or low blood pressure: Allergies: Depression/anxiety: Arthritis or gout: Diabetes: Alcohol/addiction: Bipolar disorder: Thyroid problem: Tuberculosis: Asthma: Other: Epilepsy: Kidney problems: Heart disease: High cholesterol: Stroke: Eye disease:For Women OnlySymptomPastCurrentAbdominal pain or cramping with menstruationAbnormal PAP smearAbortionBack pain with menstruation Birth control pillsBleeding between periodsBleeding during or after intercourseBloating before periodsBlood discharge from nipplesBreast lumpsHeavy bleeding with periodHot flashesSymptomPastCurrentIrregular periodsIrritabilityMenopauseMiscarriagePremenstrual tension/syndromePregnancyScanty bleeding with periodTubal ligationSickness/weakness with periodVaginal dischargeVaginal dryness or itchingPlease click the Save and Return button to complete the form later. You will be given a link sent to your email where you can return to complete the form.Save & ResumeYour TimelinePlease create a DATED timeline below (estimated year or age is good) that reflects your life’s progression in terms of: Significant life events (births, deaths, accidents, traumas, etc.) Surgeries Medications taken (include start and end date if applicable) Vaccines taken Anything else you feel is relevant to your life. My TimelinePlease click the Save and Return button to complete the form later. You will be given a link sent to your email where you can return to complete the form.Save & ResumeHomeopathic Consultation Consent/AgreementAbby Beale has been studying homeopathy since 2003. She has completed a basic two-year program PLUS six years of clinical training with the New England School of Homeopathy and continues to take professional development courses regularly. She achieved national certification (CCH) through the Council for Homeopathic Certification and is a registered member (RSHom(NA) of the North American Society of Homeopaths. Homeopathy treats underlying weaknesses and susceptibilities to the disease process by assessing through an interview the state of one’s mental, emotional and physical well-being. Homeopathy is compatible with most orthodox, complementary or alternative medical treatments, so you may choose to utilize the benefits of more than one discipline. Homeopathy by philosophy, science and practice does not diagnose or treat disease. The diagnosis and treatment of disease is solely within the license of the medical profession. If you know or suspect that you have a condition which may warrant the care of a licensed medical professional, you should see one as soon as possible.CONFIDENTIALITYI understand that all information disclosed is confidential and may not be revealed to anyone without written permission, except where disclosure is required by law.CONSULTATIONI authorize discussion of my case notes with other professional homeopaths should assistance in remedy selection and/ or symptom analysis be required (for myself or my child) or my best interest is served by such a consultation. In so doing, my right to privacy will be protected by withholding my name, but I give Abby Beale CCH permission to submit a video or audio of our consultation, or a photo (of myself or child) if needed. I also give her permission to call my home or email me if she needs to ask me further questions to assist in a remedy selection. I agree to provide a follow up interview via phone or in person at pre-determined intervals.PAYMENTPayment is expected at time of service. It can be made by Venmo (@Abby-Beale-1), PayPal (homeopathyhealings@gmail.com), credit card or check made out to “Abby Beale”. You can keep your credit card on file (securely through Square) if you desire for your convenience.Is there anything else you’d like me to know?Thank you for helping me better understand your health situation. I look forward to seeing you soon!TextareaCONSENTI am over 18 years of age and have voluntarily chosen homeopathic treatment for myself/for my child. I understand that Abby Beale CCH is a homeopath and NOT a medical doctor, and it is therefore strongly recommended that I retain the services of a primary care physician for appropriate evaluations and check-ups for myself/ for my child. I further understand that Abby Beale CCH does not diagnose, treat or prescribe for any particular symptom, disease or condition. I understand that she will work with me on increasing my/my child’s general vitality and constitutional strength.Name of Client:Name of Guardian (If applicable)Email Address:Phone/MobileToday's Date:Signature Sign Here Date / TimeSave and Submit
