Please complete, sign, and submit this online form at least 48 hours prior to your scheduled Initial Intake Appointment. Language English (US) Homeopathic Treatment Health Inventory Form Evoke Homeopathy & Wellness General Information Full Name * First Name Last Name Birth Date * January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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? Yes, 1+ pack per day Yes, 1/2 pack per day Yes, less than 1/2 pack per day I have quit I have never regularly smoked 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 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 Reasons For Seeking Homeopathic Treatment Why are you seeking homeopathic treatment? Have you had homeopathic treatment for these issues in the past? If so, how was your experience? Please list all homeopathic remedies you have taken that stand out in your memory either for their positive or negative effects. Just one last box to write anything important that you'd like me to know before we begin treatment... Signature Please sign using your computer mouse or your finger (touchscreen). Clear Save Submit Should be Empty: Now create your own JotForm - It's free! Create your own JotForm
