ADULT INTAKE FORM

ADULT INTAKE FORM
Date form completed*

DayMonthYear
Full Name*

First NameLast Name
Date of Birth - please write date / month / year*
Occupation / Vocation
Any children? please note their age/s?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
Name of your GP
GP Phone Number
GP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PRESENTING ISSUE
What brings you for treatment?
When did it START?
What factors and circumstances may have CONTRIBUTED to the onset of your condition? ie. trauma, accident, stress, surgery etc.
are there ANY OTHER SYMPTOMS or sensations that you experience? include those even seemingly unconnected?
MEDICAL HISTORY
Current MEDICAL CONDITIONS. Include any patterns of headaches, digestive problems, asthma, skin conditions & so on.
Current MEDICATIONS
MEDICATION HISTORY Please include The Pill, Morning After Pill, Antihistamines, Antibiotics, Painkillers, IVF, recreational drugs & so on.
CHILDHOOD DISEASES i.e.. whooping cough, chicken pox, measles, mumps. Please note age if known next to each.
ACCIDENTS & INJURIES including any whiplash, falls on the coccyx, broken bones, concussions & so on.
SURGERY or MEDICAL PROCEDURES including MRI's, Xrays & so on.
DENTAL WORK including any implants, root canals, extractions, amalgam fillings etc. Please note specific teeth if known
VACCINATIONS including any TRAVEL VACCINES. Please note ages/dates if known
any BLOOD TRANSFUSIONS*
do you have ANY IMPLANTS including pins, dental implants etc. Please note type if known*
TRAUMA
have there been any major TRAUMATIC EVENTS in your life? This may be loss, bereavement, injury, big change, shocking events, witnessing trauma etc.
FAMILY MEDICAL HISTORY
any HISTORY OF DISEASE IN YOUR FAMILY? ie. cancer, diabetes, rheumatoid arthritis, heart disease, alcoholism, depression etc.
FEMALES ONLY
Menstrual Cycle duration
Age Menstrual Cycle started
Pregnancies
Menopause start/finish time
GENERAL & PHYSICALS
Do you eat meat? If, so what is your favourite ie. fish, lamb, beef. pork, chicken?
What are your lifelong favourite foods?
Do you have a sweet tooth?
Do you like salty foods?
Do you like sour foods ie. lemons, vinegar?
Are you generally a thirsty person? what do you tend to drink - water, coffee, tea, herbal teas, fizzy drinks, juice, alcohol?
What is your body temperature like? Are you a chilly person? hot? do you perspire? Experience cold extremeties?
What is the quality of your sleep? Do you fall asleep easily or does it take time? Wake through the night? Dreams? nightmares? Wake unrefreshed?
GENERAL INFORMATION
Do you have a homeopathic first aid kit at home?

yesno
How did you hear about Pailin Brzeski?
CONSENT
I confirm that I request homeopathic treatment*

YesNo
I understand the need to seek appropriate medical diagnosis and treatment in the usual way.*

YesNo
I understand that Pailin Brzeski will prescribe homeopathic medicines according to the laws of the United Kingdom.*

YesNo
Signature*
Today’s DATE - day/month/year*
This form will be printed as a hard copy and placed in a locked filing cabinet.
All electronic versions will then be immediatly deleted.
Should be Empty:

ADULT INTAKE FORM

PRESENTING ISSUE

MEDICAL HISTORY

TRAUMA

FAMILY MEDICAL HISTORY

FEMALES ONLY

GENERAL & PHYSICALS

GENERAL INFORMATION

CONSENT