14127 Capri Dr, Suite 5A, Los Gatos, CA 95032

Client Name

14127 Capri Dr, Suite 5A, Los Gatos, CA 95032

1595 38th Ave, Capitola, CA 95010

(408) 823-0560

Confidential Client Information Form

Name:Date:

Gender: Date of Birth:

Address:

Phone: (H)(W) (C)

Email address:

Occupation:Employer:

FT/PT/Retired?

Marital Status (underline): Single Married Separated Divorced Widowed

Name of Primary Care Provider:

How did you hear about my practice?

Would you like to receive a newsletter?

How would you like to receive appointment reminders? Phone or Email or Text

Are you familiar with homeopathy?

Have you ever been to a homeopath? If so, please give name:

Please list homeopathic remedies you have been given by a practitioner and dates they were taken:

Do you use homeopathic remedies at home? Y N

Please outline the areas of your health that you would like to see improvement in. Please list them from most troublesome to least troublesome and list the dates you first noticed symptoms. Continue on the back or a separate page if needed.

Have you had any past experiences that still affect you deeply (trauma, accident, grief, vaccine, illness, etc.)?

Check off any childhood illnesses you have had:

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

____ Measles (2 weeks) ____ Whooping Cough ____ Asthma

____ Scarlet Fever ____ Rheumatic Fever

Write in the (approximate) year of any immunizations you have had:

______Smallpox______Tetanus______Polio

______Diphtheria______Typhoid______Flu

______Measles______Mumps______Rubella

______Chickenpox______HiB______Pneumococcal

______Hepatitis Type______Pertussis______Other List______

Check any conditions you have experienced:

Now Past NeverNow Past Never

______Addictions ______Diabetes

______Alcohol abuse ______Drug abuse

______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

Please list all prescription and over the counter medications you are taking:

Please list any vitamins, supplements, herbs, recreational drugs you are using:

Do you have allergies? To what? What is your reaction?

Is there anything else you feel I should know about you or your condition? You may continue on the back or on a separate page.

Family Health History

Relationship / Living or Deceased?
(Age and cause of death) / History of Major Disease Conditions
Mother
Father
Brother(s)
Sister(s)
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Has any blood relative had any of the following?

YesNoD.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 ______Venereal Disease

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