this is a.rtf by longze569

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									                                                  CONFIDENTIAL                                              ______/_____/______
           (905) 820-1675                                      PLEASE PRINT                                   MM           DD            YY

Last Name                                                                 Birthdate mm/dd/yy                       Age            Sex

                                                                                        /           /                                F   /M
First Name                                                                Marital Status                           Prev Married   # of Children

                                                                                 /          /           /
                                                                          Single Married Separated Widowed            Y   /N
Address                                                                   Occupation


City                                             Postal Code              Employer

                                                           -
Home Phone                      Business Phone                            Previous Homeopath / Last Visit / Previous Remedy(s)
   (         )        -            (       )          -
Email Address                                                             Referred By




Reasons For Consultation In Order Of Importance To You
Description                                                                       Started       Caused By
                                                                                  mm/yy




Surgery / Injury / Hospitalizations In Your Lifetime
Description / Cause                                                 Age           Long-term effects / Complications




Medication / Treatment / Supplements Used In The Past Year
Description / Dosage                                      Started   Stopped       Side-effects/Benefits
                                                          mm/yy     mm/yy




Immunization / Vaccination History                                    Please check appropriate boxes

       Chicken Pox                 Hepatitis A / B                    Polio                                      Tetanus
       Diptheria                   Measles                            Anti-Rabies                                Whooping-Cough/Pertussis
       Flu                         Meningitis                         Small Pox                                  Anti-Venom
       German Measles/Rubella      Mumps                              Streptococcal (Ear Infection)              Other ________________

Any adverse effects? ________________________________________________________________________________________

Any repeated vaccinations? ___________________________________________________________________________________
                                                     CONFIDENTIAL
         (905) 820-1675                                        PLEASE PRINT
Conditions You Have / Have Had In Your Lifetime                             Please check appropriate boxes

   Abscesses                                 Claustrophobia                      Hepatitis                        Prostatitis
   Abortion                                  Cold Sores                          Genital Herpes                   PMS
   ADD / ADHD                                Colds/Flu (repeated)                HIV                              Psoriasis
   AIDS                                      Colitis                             Hives                            Rheumatic Fever
   Agoraphobia                               Constipation                        Influenza (repeated)             Rubella /
   Alcoholism                                Crohn’s Disease                     Kidney Disease                    German Measles
   Allergies                                 Diarrhea (repeated)                 Leukemia                         Scarlet Fever
   Alzheimer’s                               Depression                          Lyme Disease                     Schizophrenia
   Anemia                                    Diabetes                            Malaria                          Sexual Abuse
   Animal Bites (e.g. dog / bat)             Ear Ache (repeated)                 Measles                          Sinusitis
   Anorexia / Bulimia                        Eczema                              Migraines                        Strep Throat
   Anxiety/Panic Attacks                     Emphysema                           Miscarriage                      Stroke
   Arthritis                                 Epilepsy                            Mononucleosis                    Sunstroke
   Asthma                                    Fibromyalgia                        Motion Sickness                  Syphilis
   Bi-polar / Manic-Depression               Gallstones                          Multiple Sclerosis               Tonsillitis
   High/Low Blood Pressure                   Goitre                              Mumps                            Tuberculosis
   Cancer ________________                   Gonorrhea                           Parasites                        Typhoid Fever
   Candidiasis                               Gout                                Peritonitis                      Venereal Warts
   Chicken Pox                               Hair Loss                           PID                              Warts
   Chlamydia                                 Hay Fever                           Pleurisy                         Whooping Cough
   Cholera                                   Heart Disease                       Pneumonia                        Worms
   Chronic Fatigue                           Heartburn (repeated)                Polio                            Yellow Fever

Other Conditions: ____________________________________________________________________________
Repeated illnesses (e.g. UTI’s) or conditions never fully recovered from:      __________________________

Family Health History
Relative (circle gender)              Age            Conditions
Check if alive                  Current / at Death   Indicate conditions (see above) that have affected your relatives.

    Mother

    Father

    Brother / Sister

    Brother / Sister

    Brother / Sister

    Son / Daughter

    Son / Daughter

    Son / Daughter

   Grandmother (Maternal)

    Grandfather (Maternal)

    Aunts/Uncles (Maternal)

    Grandmother (Paternal)

    Grandfather    (Paternal)

    Aunts/Uncles (Paternal)
                                                      CONFIDENTIAL
         (905) 820-1675                                       PLEASE PRINT

Amount Of The Following Consumed Weekly                          Check all Statements That Describe You
(Indicate cups, pounds, units as appropriate)

_______       Coffee                                                 Diet repeatedly
_______       Tea
                                                                     Do not exercise regularly
_______       Pop/Soda
_______       Water                                                  Repeated antibiotic use for _________________________ yr ___
_______       Alcohol                                                                            (condition).
_______       Cigarettes/Cigars                                      Exposed to chemicals at home/work ________________________
_______       Recreational Drugs
                                                                     Have traveled outside Canada / USA (most recent/common trips)
_______       Candy/Sweets
                                                                     Location ________________________________ yr ___
_______       Antacids
_______       Laxatives                                              Location ________________________________ yr ___
_______       Sleeping Pills



Miscellaneous

I am allergic to the following:__________________________________________________________________________________

Energy Scale from 0-10:      _____/ 10
(10 – I can accomplish everything I want to do in one day, 0 – I can accomplish none of the things I want to do in one day)

Mood Scale from 0-10:          _____/ 10
(10 – I feel great about my life, 0 – I feel there is nothing great about my life)

Temperature Scale from Chilly(0) to Hot(10): _____/ 10
(0 – I am the first person to put on a sweater in a group of 10, 10 – I am the last person to put on a sweater in a group of 10 people)

Perspiration Scale from None(0) to Profuse(10): _____/ 10           Location (e.g. head, feet, usual spots):______________________
(0 – I am the last person to sweat in a group of 10, 10 – I am the first person to sweat in a group of 10 people)

Digestion Tendency (circle one): Diarrhea / Constipation / Alternate between Diarrhea and Constipation


For Women Only
Age at first menstruation: __________           Age at menopause: ___________            # of Pregnancies: _________

Have used Birth Control Medication From: __________             To: ___________
                                                    yyyy                 yyyy
                                         MEDICAL / PROFESSIONAL WAIVER
A Division of 1196767 Ontario Limited
4234 Treetop Crescent,
Mississauga, Ontario L5L 2L9
Tel: (905) 820-1675


                               PLEASE READ THE FOLLOWING CAREFULLY

I, the undersigned, am exercising my right to choose an alternative method of treatment through which to
address my total health and I hereby consent to the use of this treatment.

I understand that Karen E. Jonas is a professional homeopath trained in the classical tradition and she is
not a licensed medical doctor. As such, I acknowledge that it is my responsibility to seek a medical
diagnosis and advice for present and future conditions.

I have had an opportunity to discuss the nature and purpose of homeopathic treatment with
Karen E. Jonas. I understand that results are not guaranteed.

I have read the above consent. I have also had the opportunity to ask questions about its content, and by
signing below I consent to the entire course of treatment for my present condition and for any further
condition(s) for which I receive treatment.

As homeopathic treatment is not covered by the existing government medical insurance plan, I agree to
pay all fees set by Jonas Health Centre. Payment is required in full at the end of each consultation.


Important Note: Homeopathic treatment is a health care option that works to increase the strength of
your immune system. The maximum capacity of your immune system is unique to you and depends on a
combination of the following: heredity (your parent's state of health), exposure to environmental toxins,
previous and current illness, previous and current medical treatments and many other factors.

For example, using homeopathic treatment to boost your immune system is like adding water to a water
reservoir tank. The maximum size of your water tank depends on the various factors mentioned above
(heredity, toxin exposure ...). Putting water in the tank does not guarantee rainy weather. However, a full
water tank provides a sense of security that you are prepared to survive the longest dry season possible.

Similarly, successful homeopathic treatment will help your body (immune system) respond to ANY illness
in the most effective manner possible at that time. Homeopathic treatment does NOT guarantee
improvement in ALL of your current health complaints, nor does it guarantee perfect future health.



Date: ________________________                 Client Name: _____________________________
                                                                     (Please Print Name)



                                            Client Signature: _____________________________
                                            (Parent or guardian must sign if client is under 18 years)



                                        Homeopath Signature: _____________________________

								
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