AuerFamily Homeopathy
Adult Intake Form
Name:__________________________________________ Date of Birth__________________
Home Address:_______________________________________________________________
City,State,Zip:
___________________________
Home Phone:__________________Cell Phone:_______________ Work Phone:____________
E-mail address:________________________________________________________________
Sex:
M
F
Weight
Height
Marital status ___________________
Number of children ___________________
Employment status:  Student
 Homemaker
 Disabled
 Retired
 Work full time
 Work part time
 Unemployed
 Other
Usual Occupation:
Employer:__________________________
Business/Work Address: _______________________________________________________
City, State, Zip: _______________________________________________________________
Referred by:_________________________________________________________________
Person to be contacted in case of emergency:______________________________________
Address:________________________________________
_________________________________________ Phone:_____________________
Hospitalizations -starting with the most recent (except normal pregnancies); include type of
illness, month and year hospitalized, name of hospital, city and state:
#1:________________________________________________________________________
#2:________________________________________________________________________
#3:________________________________________________________________________
Allergies:___________________________________________________________________
Please list any medications you are taking (Type, Dosage, Frequency):__________________
__________________________________________________________________________
__________________________________________________________________________
Medicinal Herbs, Vitamins, Teas:_________________________________________________
___________________________________________________________________________
Do you use:  Coffee: Amount __________
 Cigarettes: Amount ________
 Alcohol: Amount ________  Other drugs:_________ Amount ______
Tests
Chest x-ray
Electrocardiogram
TB test
GI series
Kidney x-ray
Barium Enema
Other x-rays
Year
_____
_____
_____
_____
_____
_____
_____
Immunizations
Year
Tetanus
Polio
Typhoid
Mumps, Measles
Flu
Other
_____
_____
_____
_____
_____
_____
S
Please check any of the following problems that have recently bothered you:
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frequent/severe headaches
back pains
neck lumps or swelling
loss of balance
dizzy spells
blackouts/fainting
wear glasses
blurry vision
eyesight worsening
see double
see halos or lights
eye pains or itching
watering eyes
earaches
hearing difficulties
running ears
noises in ears
dental problems
sore or bleeding gums
sore tongue
congested nose
running nose
sneezing spells
head colds
nose bleeds
sore throat
difficulty swallowing
hoarse voice
wheezing or gasping
frequent coughing
cough up phlegm
cough up blood
chest colds
rapid or skipped heart beats
chest pains
shortness of breath
swollen feet or ankles
armpits or groin swelling
difficulty sleeping
motion sickness
excessive sweating
difficulty relaxing
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recurring indigestion
frequent belching
nausea
vomiting
pain in abdomen
bloated abdomen
constipation
loose bowels
black stools
gray or whitish stools
pain in rectum
itching rectum
blood with stools
frequent urination
involuntary urination
burning on urination
black or bloody urine
weak urine stream
difficulty starting urine
constant urge to urinate
aching muscles or joints
swollen joints
back or shoulder pains
weakness in arms/legs
painful feet
trembling
numbness
leg cramps
skin trouble
scalp problems
itching or burning skin
bruise easily
nervousness or anxiety
nervous with strangers
nail biting
difficulty making decisions
lack of concentration
loss of memory
lonely or depressed
frequent crying
hopeless outlook
 Comments or special problems:
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worry a lot
scary dreams/thoughts
feeling of desperation
shy or sensitive
dislike criticism
angered easily
annoyed by little things
family problems
problems at work
sexual difficulties
change of sexual energy
considered suicide
loss or gain in weight
loss of appetite
always hungry
fatigue or weariness
fever or chills
motion sickness
night sweats
hot flashes
warm or cold than others
MALES ONLY
 burning or discharge
 swelling on testicles
 painful testicles
FEMALES ONLY
 missed period
 menstrual problems
bleeding between periods
 heavy bleeding
 bearing down feeling
 vaginal discharge
 genital irritation
 pain on intercourse
 swelling of breasts
_____# of pregnancies
_____# of births
_____# of miscarriages
_____#of premature births
_____# of caesarian
_____# of abortions
______________________________
__________________________________________________________
What are you most sensitive to (e.g. noise, odors, light, pain)?
__________________
Describe an ideal day in terms of weather and temperature:
____________
What are your fears?
________________________
Do you have any hobbies?
____________
Favorite color?
Least favorite color?
Favorite book, movie or song? _____________________________________________________
(Women only) What symptoms do you experience premenstrually?
__________________
Describe any recurrent dreams, important dreams in your life or recurrent themes in your
dreams:
How is your energy? Is there any particular time of day when it is lower or higher?
____________
How is your sexual interest/drive?
____________
What do you most like to eat or crave?
__________________
What foods do you most dislike?
How is your thirst?
What temperature do you like fluids?
____________
______
____________
Are there any foods that you are sensitive to or allergic to?_______________________________
_______________________________________________________________________