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Please complete, sign, and submit this online form at least 48 hours prior to your scheduled Initial Intake Appointment.

Homeopathic Treatment Health Inventory Form

Evoke Homeopathy & Wellness
General Information
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Gender Identification
How did you hear about Evoke Homeopathy & Wellness?
Medications
It is strongly recommended that you remain under the care of a physician. If you are taking prescribed medications, you will need these to be monitored during and after homeopathic treatment, since your need for them may change as your health improves. *

I acknowledge
What medications, supplements and over the counter items do you take regularly or are currently prescribed: *
Any past surgeries and hospitalizations? *
Have you ever been prescribed steroids (prednisone or corticosteroids) for skin issues, asthma, or anything else?
If so, please list the reason(s) and date(s) of steroid prescription(s).
How did you respond to the steroid prescription?
Sleep And Mood
What are your main interests and hobbies?
What is your line of work or study?
Do you exercise regularly?
Do you have difficulty falling or staying asleep?
How many hours do you sleep?
Do you wake up feeling well-rested?
How would you describe your energy level?
Does your energy level affect your daily activities?
How would you describe your mood, generally.
Does your mood affect your life or daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
Do you have people close to you who support you?
Diet and Lifestyle
Do you regularly drink alcoholic beverages?
If so, how many per week?
Do you smoke or chew tobacco?
Do you use recreational drugs?
How is your appetite?
How many meals per day do you eat?
Please list any food allergies, intolerances or foods you avoid and the reason.
Health History

Check items that apply to you either currently or in the past *

No, never

Yes, currently

Not currently, but within the last year

Not currently and longer than 1 year ago

Alcohol/Drug problem

Allergy/Asthma

Anemia

Anorexia

Arthritis

Binge Eating/Bulimia

Cancer

Diabetes

Epilepsy or Seizures

Heart Disease

Skin Disease

Gonorrhea

High Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Mental Illness

Obesity

Stroke

Suicide

Thyroid Disease

Tuberculosis

Ulcer

Syphilis

Check items that apply to blood relatives/family health history. *

Mother

Father

Maternal Grandparent

Paternal Grandparent

Sibling

Other

N/A