The Oyster & The Pearl

The first step of a homeopathic consultation is the intake form.

This form gives all the necessary information needed to create the accurate "symptom picture" that will lead to the choice of the correct remedy for your specific condition.

This is a sample of the homeopathic intake form for your inspection and will not print well from this page.

Once an appointment has been set, this form will be e-mailed to you.  Just print it, fill it out and return it  either by snail mail, e-mail or fax.

 Homeopathic Intake Form

Homeopathic consultation is facilitated when there is a complete picture of the individual’s mental, emotional and physical states of health.  This includes symptoms that affect both physical sensations (what does it feel like), and function (how it impacts you) and what ameliorates or aggravates each symptom.

Date: _____________________

Name ___________________________ Age___ Birth date _______Sex ___

Address_______________________________________________________

City_______________________ State ________________ Zip __________

Phone (home)_______________(work)_____________ (cell)____________

E-mail ________________________________________________________

Occupation _____________________Full-time/Part-time _____Retired____

Employed by__________________________________________________

Education_____________________________________________________

Married ____ Separated _____ Divorced_____ Widowed _____ Single_____

Are you familiar with or have you ever had Homeopathic treatment? ______.

If yes, what remedies have you taken and what remedies have helped?

___________________________________________________________

____________________________________________________________.

In your opinion, what are your most important health problems?  List as many as you can, in order of importance:

 1) ___________________________  4) ____________________________

2) ___________________________  5) ____________________________

3) ___________________________  6) ____________________________

Past Medical History:

What do you think causes or has caused your ailment or complaint? ________________________________________________________________________________________________________________________________________________

Have you had an experience (traumatic, illness, vaccine or other) that did or still affects you deeply? Explain. 

________________________________________________________________________________________________________________________________________________

The general state of my health has been:

Excellent____ Good ____Fair ____ Poor ____

What childhood illnesses have you had?

____ Rubella (3 day-measles)                 ____ Mumps                       ____ Chickenpox

____ Measles (2 weeks)                          ____ Whooping Cough       ____ Asthma       

____ Scarlet Fever                                  ____ Rheumatic Fever

Others: _____________________________________________________________

If you have had any of the following tests or immunizations, place an (X) on the appropriate line and/or give the (approximate) year.

Year        Tests                                                           Year    Immunizations

______ Chest x-ray                                                   ______ Smallpox

______ G.I. Series                                                      ______Tetanus

______ Colon x-ray (Barium enema)                  ______ Polio

______ Kidney x-ray                                                ______ Typhoid

______ Electrocardiogram                                     ______ Diphtheria                                

______ MMR                                                               ______ Flu                                          

______ Other ______________________________________________________              

Your Health History:

Now     Past     Never                         Now    Past     Never              

____    ____    ____ Addictions         ____    ____    ____ Diabetes

____     ____    ____ Alcohol              ____   ____     ____ Drugs

____     ____    ____ AIDS                   ____    ____    ____ Eczema

____     ____    ____ Allergies            ____    ____    ____ Emphysema                       

____     ____    ____ Anemia              ____    ____    ____ Epilepsy

____     ____    ____ Anorexia            ____    ____    ____ Gout                                   

 ____     ____    ____ Asthma             ____    ____    ____ Heart Condition

____     ____    ____ Bleeding             ____    ____    ____ Hepatitis

____     ____    ____ Bruising             ____     ____    ____ Herpes

____     ____    ____ Bulimia              ____      ___      ____ Hypertension

____     ____    ____ Cancer               ____    ____     ____ Kidney Disease

____     ____    ____ Colitis                ____    ____     ____ Liver Disease  

____     ____    ____ Convulsions      ____    ____     ____ Mental Disease

____     ____    ____ Depression      ____    ____     ____ Migraines        

____     ____    ____ Obesity               ____    ____     ____ Pneumonia

____     ____    ____ Rheumatism       ____    ____     ____ STD

____     ____    ____ Thyroid              ____    ____     ____ Tuberculosis  

Hospitalizations:   List as best as you can.

Type of illness/operation                       Date:           Where:

__________________________          ______        ___________________    

__________________________          ______        ___________________

__________________________          ______        ___________________

Do You Use:

Yes                         Amount                  Yes                                           Amount

____ Coffee         _________              _____ Birth Control Pills         ________

____ Cigarettes    _________           _____ Sedatives/Tranquilizers _______

____ Alcohol       _________              _____ Thyroid                          _________

____ Aspirin        _________             _____ Laxatives                       _________

____Other Drugs _________            _____ Cortisone                       _________

Yes                               Amount            Yes                                  Amount

____ Electric Blanket _________        

_____ Hormones__________________________

____ Herbs/Teas _____________        

_____ Vitamins  __________________________

 What happens when you have an “allergy attack” or “sensitivity reaction”?

Family History:

Please list ages, and if deceased, what was the cause and at what age:

Relation                      Living      Died                Cause                          Age 

Your mother                _____      _____     _____________________   _____

Your father                 _____      _____     _____________________    _____

Your brother (s)          _____      _____     ____________________    _____

Your sister (s)             _____      _____     _____________________    _____

Mother’s side

Your grandfather         _____      _____     _____________________    _____

Your grandmother       _____      _____     _____________________    _____

Father’s Side            

Your grandfather        _____      _____     _____________________     _____

Your grandmother      _____      _____     _____________________     _____

Has any blood relative had any of the following?

Yes      No       D.K. (Don’t Know)                    Yes        No         D.K.

___    ___     ___ Allergies                             ___     ___      ___ Gout

___    ___     ___ Anemia                               ___     ___      ___ Hay Fever    

___    ___     ___ Arthritis                              ___     ___      ___ Heart Attack                  

___    ___     ___ Asthma                               ___     ___      ___ High Blood Pressure

___    ___     ___ Bleeding                             ___     ___      ___ Seizure/Epilepsy

___    ___     ___ Cancer                                ___     ___      ___ Sickle Cell Anemia

___    ___     ___ Diabetes                             ___     ___      ___ Stroke

___    ___     ___ Depression                         ___     ___      ___ Thyroid Trouble    

___    ___     ___ Eczema                               ___     ___      ___ Tuberculosis    

___    ___     ___ Glaucoma                           ___     ___   ____ STD                                                                                                                                                                         Symptoms:  Please mark 1 (mild), 2 (moderate), 3 (severe) if any of the following apply to you NOW or in the PAST.

Skin

Now       Past

____     ____ skin: rough, dry, scaly, bumpy, itchy (circle)

____     ____ rashes, warts, moles, cysts (circle)

____     ____ light or dark patches of skin (circle)

____     ____ increased hair growth in unusual places

____     ____ pimples

Now     Past

____     ____ color changes in nails

____     ____ hives

____     ____ loss of hair

____     ____ ridges, pits or spots on nails

____     ____ infections, fungal symptoms

Blood, Lymph, Immune

____     ____ Swollen or painful lymph nodes

____     ____ Wounds heal slowly

____     ____ Difficulty stopping bleeding

____     ____ Swollen glands

____     ____ Bruise easily

Endocrine

____    ____ Excessive hair growth                  ____    ____ Prefer cold weather

____    ____ Cold hands or feet                          ____    ____ Unexplained thirst

____    ____ Weakness                                          ____    ____ Increased hunger

____    ____ Can’t stand cold                              ____    ____ Can’t stand heat

____    ____ Chronic fatigue                               ____    ____ Profuse sweating

Head

____    ____ Dizziness                                             ____    ____ Double vision

____    ____ Severe headaches                            ____    ____ Fainting spells

____    ____ Seizures/tics/spasms                      ____    ____ Injuries

Eyes

____    ____ Infections                                         ____    ____ Near/far sighted

____    ____ Blurred vision                                ____    ____ Floaters

____    ____ Sensitive to light                           ____    ____ Injuries

Ears

____    ____ Discharge from ears                       ____    ____ Infections

____    ____ Pain in ears                                       ____    ____ Injuries

____    ____ Hearing trouble                               ____    ____ Noises in ears

Nose

____    ____ Nose bleeds                                       ____    ____ Injury

____    ____ Sinus problems                                ____    ____ Loss of smell

____    ____ Obstruction - difficulty breathing through nose

Mouth

____    ____ Sore mouth or tongue                    ____    ____ Bad breath

____    ____ Infections                                           ____    ____ Gum disease

____    ____ Loss of teeth                                       ____    ____ Speech difficulties

Throat

____    ____ Persistent hoarseness                        ____    ____ Pain

____    ____ Difficulty swallowing                       ____    ____ Infections

____    ____ Loss of voice                                          ____    ____ Swelling

Neck

____    ____ Stiffness                                                 ____    ____ Swelling       

____    ____ Injuries

Respiratory

Now     Past

____    ____ Unexplained fever                           ____    ____ Night sweats

____    ____ Chest pain                                          ____    ____ Shortness of breath

____    ____ Wheezing                                           ____    ____ Daily cough

____    ____ Infections                                           ____    ____ Difficulty breathing

____    ____ Difficulty breathing at night (wakes you up)

Cardiovascular

____    ____ Chest pain when walking               ____    ____Varicose veins

____    ____ Ankle-swelling                                   ____    ____ Hypertension (HBP)

____    ____ Shortness of breath                           ____    ____ Leg pain (walking)

____    ____ Heart palpitations (fluttering, pressure, skipping, rapid beat) 

Digestive System    

____    ____ Frequent or severe symptoms            ____    ____ Vomiting, nausea

____    ____ Blood in stools                                           ____    ____ Hemorrhoids

____    ____ Change in bowel movements              ____    ____ Black stools

____    ____ Heartburn                                                ____    ____ Vomiting blood

____    ____ Indigestion                                                ____    ____ Anal itching

____    ____ Excessive belching                                 ____    ____ Yellow jaundice

____    ____ Stomach pain                                          ____    ____ Diff. swallowing     

____    ____ Distress from fats or greasy foods

____    ____ Stools yellow, clay-colored, foul odored, has undigested food

____    ____ Bad breath, bad taste in mouth; body odor (including feet)

____    ____ Indigestion after meals (fullness, bloating, sourness, etc.)

____    ____ Heavy, full feeling after eating

____    ____ History of constipation or diarrhea

____    ____ Excessive lower bowel gas

____    ____ Stomach pain occurs 5 or 6 hours after eating

____    ____ History of constipation or diarrhea

____    ____ Indigestion occurs immediately after eating

____    ____ Nervousness, shaky feelings, headaches, relieved by eating

____    ____ Irritable if late for meal, miss meal, or before eating breakfast

____    ____ Sudden, strong craving for sweets or alcohol

____    ____ Wake up at night feeling hungry

____    ____ Overweight                                        ____    ____ Loss of appetite

____    ____ Sudden weight loss                           ____    ____ Sudden weight gain

____    ____ Infection                                              ____    ____ Injury

____    ____ Sleepy during the day?  When? __________________________________

How often do you have bowel movements?____________________________________

Do you strain at stool? _____.  Have you had a change of appetite? _________Increase / decrease? ______________.Of what does your diet consist ? ___________________ ____________________________________________________________________

____________________________________________________________________

Do you snack?_______.  On what? _________________________________________

___________________________________________________________________

What foods, condiments, or any other substances (i.e. chocolate, ice-cream, mustard, sour, spicy, etc.) do you crave? _________________________________________________________

Are you repelled by, or do you dislike any foods? _____________________________________________________________________

Urogenital  System

Now    Past

____    ____ Frequent urination                                ____   ____ Painful urination

____    ____ Night urination                          

____    ____ Trouble starting urine                           ____   ____ Trouble holding

____    ____ Frequent urging with scant urination

Male Problems

____    ____ Any prostate problems

____    ____ Discharge from penis

____    ____ Difficulty achieving or maintaining an erection

____    ____ Painful erection

____    ____ Difficulty with ejaculation

____    ____ Lumps, swelling or pain in testicles

____    ____ Infection

____    ____ Infertility

____    ____ Injury

Female Problems

____    ____ Discharge from vagina

____    ____ Difficulty feeling sexually aroused

____    ____ No lubrication when aroused

____    ____ Never or seldom have orgasms

____    ____ Sex is painful                                       ____  ____ Pelvic pain

____    ____ Menstrual flow is excessive/absent (circle)

____    ____ Bleeding or spotting between periods

____    ____ Pain before, during/after periods (circle)

____    ____ Infection                                              ____  ____ Infertility

____    ____ Lumps in breast

Spine and Extremities

____    ____ Joint pain, swelling, stiffness, tingling, numbness

Where? _________________________________________________________________

____    ____ Muscle cramps                                    ____   ____ Backaches

____    ____ Burning soles of feet

____    ____ Unusual redness of palms of hands

____    ____ Injuries

____    ____ Other

Have you ever had arthritis? __________ 

Where _________________________________What kind ________________________

Nervous System

Now     Past

____    ____ Loss of balance                                  ____   ____ Paralysis

____    ____ Lack of strength (seizures, stiffness)

____    ____ Convulsions                                       ____   ____ Numbness

____    ____ Tremor (shaking, involuntary movements, tics, spasms)

General

Are you a warm or chilly person? __________________________________

Are you sensitive to changes in weather?  ______ sun ­______ drafts ______

wind _­__ noise ___  ordered environment _____ other _________________ _____________________________________________________________

When in bed, if you feel warm, what part of your body would you tend to uncover first? __________________.  Do you usually dream? _______.  Are there specific dreams or recurring themes to your dreams?

If so, what?___________________________________________________________

________________________________________________________________________

Mental/Emotional

Now     Past

____    ____ Restlessness                                      ____    ____ Anxiety

____    ____ Excessive worry                              ____    ____ Nervousness

____    ____ Memory trouble                              ____    ____ Trouble concentrating

____    ____ Depression                                         ____    ____ Crying spells

____    ____ Trouble sleeping                              ____    ____Nightmares                                   

____    ____ Trouble getting along with people

____    ____ Easily angered                                 ____    ____ Feelings of worthlessness

____    ____ Mood swings                                      ____    ____ Suicidal thoughts

____    ____ Fearful                                                ____    ____ Excess stress

____    ____ Loss of someone dear through death or separation

____    ____ Always put others’ interests before mine

____    ____ See things that others don’t

____    ____ Hear voices

____    ____ Think others want to hurt you

____    ____ Don’t know how to relieve stress

____    ____ Is order important to your surroundings?

____    ____Are you generally late for appointments?

____    ____ Do you tend to leave things undone until the last minute

____    ____ Peculiar sensations?  What? ____________________________

Where?_______________________________________________________

How do symptoms of stress show up in you (physically/emotionally)?

________________________________________________________________________________________________________________________________________________

What are your triggers for stress_______________________________________________________________ ___________________________________________________________________

__________________________________________________________________________________________How How do you alleviate stress?_______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Is there anything else you wish to add? 

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Homeopathic Disclosure & Informed Consent

I understand that a homeopathic remedy may be given with this consultation or be suggested for purchase at a store of my choosing. 

If given at the time of consult and needed to be repeated before the next consult, a $10.00 remedy fee (plus shipping if necessary) will be charged.   

I confirm that any prescription medications I am taking under the care of a physician will not be withdrawn without his/her supervision.

 I understand that a block of time has been set aside for my private appointment and that a 24-hour notification is required if I must cancel. 

I understand that there is a fee of one consult hour ($95.00) for appointments canceled less than 24 hours in advance. (This also applies to coaching programs)

I understand that payment is due at the time services are rendered, unless other arrangements have been made prior to the appointment.

I understand that phone consultations will be billed at the usual hourly rate.

I understand that current fees for single consultations are as follows, but that there may be changes in the fee structure in the future. (Coaching Program prices differ.)

       Initial Single Consultations           $195.00 (120 minutes)

 Homeopathy is considered to be an alternative/preventative system of health care and is not intended to be a substitute for allopathic or traditional medicine.

The therapy and information offered should not be construed by you, the client, or any family, friends or caregivers to be a medical diagnosis of any disease or injury.

You should consult with your physician for any serious medical condition and further, you should get at least two medical opinions for such condition.

While Michele S. Morgan, M.H., Ph.D. has had extensive training in the science and art of Homeopathy, Bach Flower Therapy & Botanicals, she is neither a medical doctor nor a licensed physician.

 I HAVE READ THE ABOVE AND AGREE TO ALL TERMS:

Signature:  ________________________________.      Date: ____________

If patient is under 18 years, parental signature is required.