Julia Mandle Homeopathy Clinic– 53 Sierra Street, Glendowie, Auckland, 1071 027 372 5451
Please fill in this form with as much detail as possible and email it to me. All information is private and confidential.
I WAS RECOMMENDED TO YOU BY:
DATE OF BIRTH:
DESCRIBE BRIEFLY YOUR MAIN REASON(S) FOR CONSULTING A HOMOEOPATH:
ORIGIN OR CAUSE: Can you trace the origin of the present illness to any particular circumstance, accident, illness, incident or mental upset? (e.g. Shock, worry, errors in diet, overexertion, exposure to cold, heat etc.)
LIST ANY MEDICATION THAT YOU ARE CURRENTLY TAKING ( INCLUDING THE CONTRACEPTION PILL, VITAMINS AND FOOD SUPPLEMENTS):
GIVE DETAILS OF ANYTHING THAT YOU ARE ALLERGIC TO – FOODS, DRUGS, ANIMALS ETC.:
FAMILY HEALTH HISTORY.
Please give details of the health history of your relatives. For example:
Diabetes, heart disease, cancer, tuberculosis, thyroid, mental disease, suicide, alcoholism, etc.
INCLUDE FATHER, MOTHER, GRANDPARENTS, BROTHERS, SISTERS, UNCLES AND AUNTS:
PERSONAL HEALTH HISTORY
Please fill in this section giving as much information as possible including dates. Remember to mention your approximate age at the time of any health problems.
ABOUT YOUR BIRTH if known: (your birth weight? Did your mother have any problems during pregnancy? Did she take any drugs during pregnancy? Were there any problems during labour? Were you breastfed?)
INFECTIOUS CHILDHOOD DISEASES: (Measles, mumps, chicken pox, whooping cough, glandular fever etc. / State if mild or severe):
ANY ADVERSE REACTIONS TO IMMUNISATIONS/VACCINATIONS:
INJURIES AND ACCIDENTS:
OPERATIONS AND SURGICAL PROCEDURES:
SKIN: Warts, verrucae, herpes (cold sores), abscesses, boils, moles, eczema, impetigo etc.
WEATHER & ENVIRONMENT REACTION: (What weather suits you best? Do you feel the cold/heat/wind/drafts/damp/humidity? Do you prefer warm rooms or desire fresh air etc.?)
APPETITE & THIRST: (What foods/drinks/flavours/condiments etc. do you either crave or have a strong dislike of? Does any food or drink cause an adverse reaction? How thirsty are you?)
FEARS OR PHOBIAS: (For example – heights, closed spaces, dark, germs, ghosts, animals, insects, snakes, spiders, storms, examinations, disease, poverty, failure etc.)
DREAMS : (Any dreams that stay in your memory. Any recurring dreams. Include childhood dreams. Please try to recall at least one dream that you have had in your life.)
ANY OTHER HEALTH PROBLEMS INCLUDING LIFE TRAUMAS, GRIEFS, SHOCKS ETC. CONTINUE ON A SEPARATE A4 SHEET IF NEEDED: