ADULT FORM

ADULT HEALTH HISTORY

CLIENT DETAILS

Name*

First Last

Age*

Sex*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Email

Occupation

What problem are you seeking help for?

List all complaints in order of importance to you:

Complaint:

Since:

Causes/triggers:

List any factors that make these complaints better or worse (ie. foods, time of day, temperature ect.):

List any medications/supplements/herbs you are currently taking:

List any other therapies you have done or currently are doing:

List any surgeries you have had and when:

Surgeries:

Date

Complications:

Are there any conditions or situations after which you have never been well again? Explain.

Have you had any serious shock, grief, disappointment, fright ect?

Do you suffer from any allergies? If so please list and symptoms experienced.

Do you suffer from any of the following digestive symptoms? Please check.

gas
bloating
indigestion
constipation
diarrhea
cramping
fullness
heaviness
pain

Any reactions to childhood vaccinations? If yes, please describe

Any chronic or repetitive childhood/adolescent/adult illnesses? (ie. Strep, ear infections ect.)

List any known illnesses or health issues of close family members

List any foods that you love or crave.

List any foods that you dislike or upset you.

Do you have any fears or phobias? (ie. heights, bridges, snakes ect.) Please list and explain,

What is your desired outcome from your consultation?

Please list any other information you would like me to know.

This information is strictly confidential. Any information obtained during this consultation is confidential.

Please read and sign below.

* I understand that Krista Rivet is not a physician and can neither diagnose nor treat any illness. She is a certified classical homeopath and the relationship between myself and Krista Rivet is one of educator and client. I acknowledge that it is my right and responsibility, at any time throughout my consultations with Krista Rivet to seek medical treatment and diagnosis if so desired by a medical doctor for any present/future condition. I acknowledge that the state of my health is my responsibility and that I am exercising my right to choose an alternative method by choosing homeopathy. By signing below I am stating I am aware and acknowledge all of the above and will choose whether to use the advice/education by Krista Rivet. In the event of an emergency, I must seek the help of a medical doctor.

Consent*

I agree

Date