Booking

1. Personal Details

Full Name *

Email Address *

Phone (Mobile) *

Date of Birth

Address & City

Occupation

2. Reason for Consultation

What has brought you to homeopathy today? *

How long have you had this complaint?

What do you think triggered it?

3. Current Health & Medical History

Current diagnosed conditions:

Current medications and supplements:

Known allergies or sensitivities:

Past illnesses or hospitalisations (with dates):

4. Family Medical History

Mother

Father

Siblings / Grandparents

7. Sleep

Usual sleep time

Hours per night

Sleep Issues:

Difficulty falling asleep Waking in the night Vivid dreams Unrefreshing sleep

8. Food & Appetite

Food Cravings:

Food Aversions:

Do certain foods aggravate your symptoms?

Yes No

If yes, which?

10. Women's Health

Check this box if applicable to fill Women's Health section

Cycle length (days)

Menstrual symptoms

Menopausal or hormonal concerns:

11 & 12. Skin, Lifestyle & Energy

Exercise habits:

Energy levels (1-10)

13. Previous Treatment

Have you had homeopathic treatment before?

Yes No

If yes, remedies and response:

14. Consent & Declaration

I understand that homeopathy is a complementary therapy and does not replace conventional medical care. I consent to my data being processed securely.

New Patient Intake Form