Reflections Homeopathy

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Intake Form

Intake Form

Thanks for your interest in becoming a Reflections client. Please fill out the form below to the best of your ability so that we can get to know your health history. If you have any trouble with the form below or would rather download and submit a PDF you can access that here: Intake Form. Fields with a "*" are required. You may also review our Terms of Service (link loads in another tab). If you are under 18 a parent or guardian must also fill out the consent form here: Consent Form.

Full Name*

Contact E-mail Address* (if under 18 provide your parents E-mail address)

Home or Cell Number*

Current Health Concerns (please describe or list)

Have you seen an MD for your current problem(s)?

Yes

Have you taken homeopathic remedies before?

Yes

Have you visited alternative medicine practitioners?

Yes

Do you smoke?

Yes

Please list or describe any past illnesses

Please list or describe any past hospitalizations

Please list any medications or vitamins you take now or have taken:

Current Medications Past Medications Vitamins

Family History

Please provide the age, state of health and past illnesses of family members. If deceased, please include the cause of death.

Father

Mother

Father's Mother (Paternal Grandmother)

Mother's Mother (Maternal Grandmother)

Father's Father (Paternal Grandfather)

Mother's Father (Maternal Grandfather)

If you are under 18 please have a parent or guardian fill out the consent form here: Consent Form.