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New Client Intake Form

Flora and Fauna Classical Homeopathy Client Questionnaire

  • Background Information

  • Notice Regarding Homeopathic Services in California

  • I am aware that homeopathy may be practiced as an alternative healing art in California under sections 2053.5 and 2053.6 of the Business and Professions Code subject to these requirements and restrictions:
    • 1) that the practitioner states s/he is not a licensed physician or health-care provider
    • 2) that homeopathic consulting services are not licensed by the state
    • 3) that homeopathic consulting is not represented as nor intended to be a substitute for conventional medical diagnosis or treatment and that it does not diagnose or treat specific pathological conditions or disease symptoms
    Acknowledgment I understand homeopathy is a means of stimulating an individual's vital energy, using homeopathic remedies with the aim of increasing the general well-being of the whole person. I understand that homeopathic services are not medical treatment and that the homeopath is not a licensed physician. I will not hold Alexis White or flora & fauna classical homeopathy liable for my overall health or well-being. If 'client' is a minor, I acknowledge that all parents consent to homeopathic treatment for their minor child with Alexis White and flora & fauna classical homeopathy.
  • Reset signature Signature locked. Reset to sign again
  • Health Information

    All information is kept confidential.
  • Lifestyle

    Which of the following substances do you consume. Specify frequency and amount.
  • Food Cravings

    Using the drop-down menu below each item, indicate your strong food cravings or aversions by using a scale of -3 to +3. Indicate if you have no cravings. (No need to rate foods you feel neutral about).

  • Very averse is -3 | Neutral is 0 | Strongly crave is 3

  • Medical and Health Symptom History

    Please check the box for any symptom that has been an ongoing issue for you. Please indicate past or present symptoms. At the end of the entry add any details you feel are relevant and important:
  • For the symptoms above provide any details you feel are relevant and important.
  • Any other major conditions not listed here? Or any long-term effects of the above symptoms?
  • List any surgeries or medical procedures & dates:
  • Family History

    Please check the box for any illness or disease. Please consider and include (if known) the following: parents, siblings, aunts/uncles, cousins, grandparents, great uncles/aunts, great grandparents.
  • Indicate if there is/was any ailment or illness that affects more family members than you were able to indicate in the above form. List details here.
  • Any other major ailments not listed here? List person and condition:
  • Any losses or major accidents that have had a great impact on your family?
  • This field is for validation purposes and should be left unchanged.

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Quick Links

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Notes from Alexis

  • Quieting your inner critic January 31, 2023
  • Thyroid Health in the News: endocrine disruptors December 2, 2022
  • Getting the flu: control what you can control October 17, 2022

Contact

Office Address:
508 San Anselmo Ave. #19, San Anselmo, CA 94960

P: (415) 457-3225

E: Alexis at florafaunahomeopathy.com

© 2023 Flora & Fauna.

  • Home
  • About Alexis and Her Practice
    • Biography
    • Alexis’ story
    • Services
  • About Homeopathy
    • Why choose homeopathy?
    • What is homeopathy?
    • Past Webinars & Classes
    • Frequently Asked Questions
  • Work With Me
    • New Client Intake Form
  • Notes from Alexis
  • Contact