Subject
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Today's date:
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Age:
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Main symptoms and any formal diagnoses that you have:
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Any additional symptoms or health issues you'd like to add—none are too big or too small:
Overall sense of health and wellness, where 1 is terrible and 10 is great:
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Energy, on the same scale from 1-10:
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Mood, on the same scale from 1-10:
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Emotional tendencies (when under stress, tending towards: depression, sadness/crying, anxiety, quick temper/anger, swings, balanced/even keel, not feeling much—good or bad, etc.):
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Non-pharmaceutical supplements and/or other treatments you’re currently using:
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Pharmaceuticals you are currently taking:
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Any past homeopathics you’ve used and what effects they had:
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Do you frequently use (please be honest—there's no judgment, it’s because the dosing style often needs to be different with frequent use of any of the following. If you're not comfortable admitting to one, just check the box of a less charged option.):
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