Adult Registration Form • Patient Central • Classic Homeopath

Directions • Registration Forms • Preparing for Your Consultation • Antidotes to Avoid • LM Instructions • Is My Remedy Working?

Please fill out as completely and throughly as possible and do not leave any fields blank.

Note: The information you provide here is kept private and coinfidential in accordance with Federal HIPPA Laws.

* Denotes required field

First and Last Name: A value is required.A value is required. *
Birthdate: A value is required.Invalid format. *
Street Address: A value is required. *
City: A value is required. * State: Please select an item. * Zip code: A value is required.Invalid format. *
Home phone: A value is required.*
Work phone: A value is required. *
Cell phone: A value is required. *
Email address: Invalid format.A value is required. *
Gender: Please select an item. *
Employment status: Please select an item. *
Occupation: *
Employer name:
Marital status: Please select an item. Number of children: * A value is required.Invalid format.

Referred by:
Emergency contact person: A value is required. *
Emergency contact address: *
Emergency contact phone: A value is required.*

Give the following information for the last times you have been hospitalized
starting with the most recent (except normal pregnancies); include type of
illness, month and year hospitalized, name of hospital, city and state.
1.

Allergies:
Current medications (type, dosage, frequency):
Currently used medicinal herbs, vintamins, teas:

Do you use:
Coffee If yes, amount:
Cigarettes If yes, amount:
Alcohol If yes, amount:
Other drugs If yes, amount:

Year	Tests	Year	Immunizations
	Chest X-Ray		Smallpox
	Electrocardiogram		Tetanus
	TB Test		Polio
	GI series		Typhiod
	Kidney X-Ray		Mumps, Measles
	Barium Enema		Flu
	Other X-Rays (please list):		Other (please list):

Check the corosponding box if any of these options apply to you:

frequent or severe headaches	recurring indigestion	aching muscles or joints
back pains	frequent belching	swollen joints
neck lumps or swelling	nausea	back or shoulder pains
loss of balance	vomiting	weakness in arms or legs
dizzy spells	pain in abdomen	painful feet
blackouts/fainting	bloated abdomen	trembling
wear glasses	constipation	numbness
blurry vision	loose bowels	leg cramps
eyesight worsening	black stools	skin problems
see double	grey or whitish stools	scalp problems
see halos or lights	pain in rectum	itching or burning skin
eye pains or itching	itching rectum	bruise easily
watering eyes	blood with stools	nervousness or anxiety
earaches	frequent urination	nervous with strangers
hearing difficulties	involuntary urination	nail biting
running ears	burning on urination	difficulty making decisions
noises in ears	black or bloody urine	lack of concentration
dental problems	weak urine stream	loss of memory
sore or bleeding gums	difficulty starting urine	lonely or depressed
sore tongue	constant urge to urinate	frequent crying
congested nose	hopeless outlook
running nose	difficulty relaxing	MEN ONLY
sneezing spells	worry a lot	burning or discharge
head colds	scary dreams or thoughts	swelling on testicles
nosebleeds	feeling of desperation	painful testicles
sore throat	shy or sensitive
difficulty swallowing	dislike criticism	WOMEN ONLY
hoarse voice	angered easily	missed periods
wheezing or gasping	annoyed by little things	menstrual problems
frequent coughing	family problems	bleeding between periods
cough up phlegm	problems at work	heavy bleeding
Other:		bearing down feelings

What are you most sensitive to (eg. noise, odors, light, pain)?

Describe an ideal day in terms of weather and temperature:

What are your fears?

Do you have any hobbies?

(Women only) What symptoms do you experience premenstrually?

Describe any recurrent dreams, important dreams in your life or recurrent themes in your dreams:

How is your energy? Is there any particular time of day when it is lower or higher?

What environment do you feel most comfort in? (ie desert, mountains, ocean, city)

How is your sexual interest/drive?

What do you most like to eat or crave?

What is your favorite color?

What foods do you most dislike?

How is your thirst?

What temperature do you like fluids?

Are there any foods that you are sensitive to or allergic to?

Family History

Click the checkbox in the appropriate columns for any illnesses that you or your relatives have had:

Illness	Self	Father	Mother	Brothers	Sisters	Child #1	Child #2	Child #3	Grandparents
Allergies
Anemia
Arthritis/Gout
Bleeding Problems
Cancer
Epilepsy
Diabetes
Alcohol/Drugs
Eczema
Emphysema
Heart Trouble
Hepatitis
High Blood Pressure
Frequent Infections
Kidney Problems
Mental Illness
Migraines
Abnormal Periods
Psoriasis
Pneumonia
Polio
Prostate Problems
Rhuematic Fever
Stomach Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Weight Problems

Any extra questions, comments, or information: