WELCOME

AUCKLAND HOMEOPATHY INTAKE FORM

For all FIRST CONSULTATIONS:
Please fill out the intake form below to enable me to prep for your appointment.

My aim is to find the best remedy to suit you. This is a bit like finding the right key for a car. Once you have the key, the engine will start and the healing process will begin. As there are over 3000 homoeopathic remedies, this can be challenging sometimes, but it is well worth it. Homeopathy is a holistic medicine and we take into account everything that is happening in your body. To help me get the most accurate results please complete the following questions and anything else you can think of, in your own language.

Just write in as much detail as possible about your conditions and what you need help with.

Intake Form

First Name *

Last Name *

Phone

Email *

Address

Date of Birth

How did you hear about us? How did you hear about us?

Select your preferred practitioner: *

Janine Gawn

Rebecca Stirrup

Goals

What are your goals in terms of health and wellbeing for you or your child?

Current Symptoms

Please explain, in as much detail as possible, what is your reason for consulting me? Can you put your issues on a timeline of when they started? When and how did it start? What caused it? Can you suggest some factors that helped create these symptoms? Does anything make it better or worse? (e.g. standing, afternoon, after sleep, hot or cold, pressure etc.) Please describe anything that you feel is associated with the current symptoms that is unusual or peculiar or any other information, which you wish to add.

Other Symptoms

Go over your body from head to toe and think about for any other problems you might have? (Head, ears, nose, throat, chest, digestive problems, urinary problems, joints, skin, hands or feet).

Cognitive Symptoms

Please list any problems with thinking, concentration or memory.

Menstrual History

Hormonal contraceptives used now or in past, what age(s)? Date of first day of your last period? How often does your cycle occur? How long does it last? Any pain/cramps, where? describe pain? Flow heavy/med/light? Anything that occurs at the same time as the period? E.g. headaches, nausea, vomiting, breast tenderness etc. Any premenstrual tension / moods and how do you experience this?

Emotional Symptoms

List any major emotional reactions - irritable, anxiety, anger, grief, fears or phobias that affect you strongly.

Important Events

It would also be very useful if you could describe any particular important events in your life. How did you feel about them at the time? Also, how do you feel about them now?

General Symptoms

How does your body react in general? eg cold hands and feet etc. Are you a hot or cold person? Does the weather (hot, dry, damp, cold etc.) affect you or your condition? Do you sweat easily? Are you thirsty?

Food

Please list any foods/flavours that you especially love or hate, or cause you problems.

Medical history / Medication

Please list all relevant medical history, including medications you are taking.

Family History

Please list any illnesses/issues in your family – especially parents, grandparents, siblings.

Notes / Comments

If you are human, leave this field blank.

All information will be treated with the strictest confidentiality.

WELCOME

AUCKLAND HOMEOPATHY INTAKE FORM

For all FIRST CONSULTATIONS: Please fill out the intake form below to enable me to prep for your appointment.

For all FIRST CONSULTATIONS:
Please fill out the intake form below to enable me to prep for your appointment.