Intake Form - Homeopathy Healings

Intake Forms

Homeopathy Healings - Abby Beale CCH RSHom(NA)
homeopathyhealings@gmail.com
413-426-1024

PLEASE 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:

Date

Address:

City:

State:

Zip:

Cell Phone:

Email:

Age:

Date of Birth:

Occupation:

Referred by

In 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.

Please 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.

Self-Care Rituals

Feel 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.

Symptoms

Please MARK those symptoms you have ever experienced AND/OR are typical for you.

General

Personal Notes for Generals

Cardiovascular

Personal Notes for Cardiovascular

Head, Eyes, Ears, Nose and Throat

Personal Notes for Head, Eyes, Ears, Nose and Throat

Genital-Urinary

Personal Notes for Genital-Urinary

Respiratory

Personal Notes for Respiratory

Gastrointestinal

Personal Notes for Gastrointestinal

Musculoskeletal

Personal Notes for Musculoskeletal

Neuro-Psychological

Personal Notes for Neuro-Psychological

Skin and Hair

Personal Notes for Skin and Hair

Please list your most frequent childhood illnesses and usual treatment

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Vaccinations (check any that apply).

Please list all current medicines and supplements

Family history (grandparents, parents, siblings) - check any that apply and list family member(s) in the blank.

For Women Only

Symptom

	Past	Current
Abdominal pain or cramping with menstruation
Abnormal PAP smear
Abortion
Back pain with menstruation
Birth control pills
Bleeding between periods
Bleeding during or after intercourse
Bloating before periods
Blood discharge from nipples
Breast lumps
Heavy bleeding with period
Hot flashes

Symptom

	Past	Current
Irregular periods
Irritability
Menopause
Miscarriage
Premenstrual tension/syndrome
Pregnancy
Scanty bleeding with period
Tubal ligation
Sickness/weakness with period
Vaginal discharge
Vaginal dryness or itching

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.

Your Timeline

Please 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 Timeline

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.

Homeopathic Consultation Consent/Agreement

Abby 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.

CONFIDENTIALITY

I understand that all information disclosed is confidential and may not be revealed to anyone without written permission, except where disclosure is required by law.

CONSULTATION

I 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.

PAYMENT

Payment 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!

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CONSENT

I 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/Mobile

Today's Date:

Signature