Patient Forms

Please choose the appropriate form: Homeopathy for a homeopathic consultation, Nutrition for a nutrition consultation.

HOMEOPATHY
Patient intake form for homeopathic care

GENERAL PATIENT INFORMATION

STATUS

I LIVE WITH..

MAIN COMPLAINTS - List all physical, mental, emotional

Approximate date of onset

MEDICAL DIAGNOSES

SURGERIES & HOSPITALIZATIONS (Please list all surgeries and hospital stays including childbirth, emergencies, etc.)

MEDICATION - CURRENT AND PAST

List all medications including laxatives, appetite suppressants, tranquilizers, pain relievers, antacids, sleeping aids, birth control, creams or gels, homeopathic remedies, nutritional supplements etc.

TREATMENTS

MEDICAL AND SYMPTOM HISTORY - check all conditions past and current

Immunizations (since birth)

ADDITIONAL INFORMATION

PLEASE READ THE FOLLOWING CAREFULLY (if under 19 years of age, a parent or guardian must sign.) I understand that Chantal Calais is a homeopath and not a licensed medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. In consulting with Chantal Calais, I am exercising my right to choose an alternative method of treatment through which to address my total health. I agree that “symptoms” from my consultations may be used for homeopathic teaching purposes. I acknowledge that all personal information will be kept confidential.
NUTRITION
Patient form for nutrition consultation

GENERAL PATIENT INFORMATION

MEDICAL DIAGNOSES

SURGERIES & HOSPITALIZATIONS (Please list all surgeries and hospital stays including childbirth, emergencies, etc.)

MEDICATION - CURRENT AND PAST

List all medications including laxatives, appetite suppressants, tranquilizers, pain relievers, antacids, sleeping aids, birth control, creams or gels, homeopathic remedies, nutritional supplements etc.

MEDICAL AND SYMPTOM HISTORY - check all conditions past and current

ADDITIONAL INFORMATION

PLEASE READ THE FOLLOWING CAREFULLY (if under 19 years of age, a parent or guardian must sign.) I understand that Chantal Calais is a homeopath and not a licensed medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. In consulting with Chantal Calais, I am exercising my right to choose an alternative method of treatment through which to address my total health. I agree that “symptoms” from my consultations may be used for homeopathic teaching purposes. I acknowledge that all personal information will be kept confidential.
Contact / RDV

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