First Full Appointment Intake

Thank you for booking your first full homeopathic consultation.

Please fill out the form below prior to your appointment.

ACKNOWLEDGMENT: Upon booking your appointment you are acknowledging your choice for homeopathic treatment. Submitting this form indicates that you have read and accepted the following DISCLOSURE: Shelly Garrison CCH, is a board certified homeopath and not a medical doctor and cannot make diagnoses, or treat or prescribe for any particular disease or condition. It is recommended that you retain the services of a primary care physician for appropriate evaluations and check-ups for yourself/child. It’s always wise to see your doctor for any serious problem. Once you know what you are dealing with you can choose your treatment mode. Homeopathy can be used alongside conventional care when needed.

Name

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Address

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Age

What health issue prompted you to make this appointment? *

Main complaint - What is the main complaint or symptom(s) you would like help with?

Medication - Please list medications you are currently taking or have taken in the last 10 years. Include Illnesses, diagnoses, medical procedures, surgeries.

Vaccination - Please list any vaccinations you have had recently and historically. Please include the brand names if you know.

Allergies - Do you have any allergies? Please describe.

Family history - What diseases, illnesses or conditions are there in your family history (parents, grandparents, etc)? What have your family members died of or from?

Trauma - What shock, traumas, toxic exposures, or notable events have you experienced in your life?

Generational Trauma - What shock, trauma, toxic exposures or notable events are there in your family history including immigration, war, occupational, or high stress situations? What themes or generational patterns exist?

Occupation - What is your occupation? What kind of work do you do or have you done? What kind of work did your parents and grandparetns do?

Thermal/Climate - Are you hot or chilly? What climate do you most enjoy? Please describe.

Food - What are your favorite foods and drink? Please describe.

Likes/Dislikes - What do you enjoy? What activities or hobbies? What do you dislike or avoid?

Fear/Anxiety - Do you have any particular fears? Anxieties? Stress points? Briefly describe.

Dreams - Do you recall your dreams? Are there any common themes that repeat?

Relationships - What is the quality of your relationships? How do you feel about your relationships?

Ease - How comfortable are you in your body, mind, spirit? On a scale of 1-10 (10 being the most easful, relaxed, content, connected).

Who are you? Briefly describe yourself.

Homeopathic remedy sources - Do you currently have access to homeopathic remedies for acute care prescribing: a basic kit or lab connection?

How do you want to meet?

How did you find Shelly?

Agreement: It is my choice to work in collaboration with Shelly Garrison, CCH, board certified homeopath, while also assuming responsibility for my health.

Yes

First Full Appointment Intake

Thank you for booking your first full homeopathic consultation.

Please fill out the form below prior to your appointment.

Shelly Garrison, CCH
HomeopathY

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