New Client Information and FormsOnce filled out please email to Shellyjwotton@gmail.com Intake Form Shelly Wotton, CCH 978-877-3947Shellyjwotton@gmail.com Name Date Date of Birth Date of Birth Home Phone Cell Phone Address: Subject Homeopathic Intake Form Homeopathy is a part of science that is based on the idea of “like cures like” and is individualized for each person. The client will require a remedy that is the most similar to the symptoms that he/she is experiencing so that it can help the body to heal itself. This is why it is so important to have a good understanding of the client so that the appropriate remedy is selected to have the greatest benefit. This intake is extremely confidential and will never be revealed to others. Chief complaint(s): Describe the exact character of the complaint(s) with any specific sensations, time of occurrence and duration of days, months or years it has been present. If more than one complaint, please list in the order of priority you would like to address. What happened in your life around the time of the complaint(s)? What do you think caused it? What aggravates the problem (certain types of food or weather, movement, light, noise, heat/cold, ect.? At what time of the day or night is the problem the worst? Specify an hour if you can. What symptoms can you identify that accompany the problem? WOMEN : Number of pregnancies Number of children Number of miscarriages Number of abortions At what age did menses (period) begin? If you have gone through menopause, at what age? How frequently does (or did) your period come? What about the duration, abundance, color, time of day when flow is greatest, any odor or clots? How do you (did you) feel before, during and after menses? Any PMS symptoms? HEALTH HISTORY : Frequency of bowel movements (BM) ? How frequently do you get colds and flus? Have you had any childhood illnesses twice, or in a very severe form, or after puberty? Have you had vaccinations since the standard childhood ones? Have you ever had an adverse reaction or unusual reaction to vaccinations? Have you had any surgery? What type and when? FAMILY HISTORYf : List Mental diseases, physical diseases, causes and ages of death of parents, siblings and grandparents on both sides. Brothers/sisters: Parents : Mother : Parents : Father : Grandparents--Maternal : Mother : Father : Grandparents--Paternal : Mother : father : List or give sheet of present medications you are taking—tell us to the best of your knowledge the reason you were prescribed this medication. How long have you been taking each medication? List any supplements (vitamins) and herbs you are taking or give a sheet with them and why you are taking them and how long you have been taking them. Are you presently on any Homeopathic remedies? If so, which one and what is the potency, dose and how often do you take it? Have you had any adverse reactions/aggravations to any remedies? Please include anything else that you feel is pertinent to your case or that would be helpful to know about you. Informed Consent Shelly Wotton, CCH WottonsWellness, LLC Client Name Date of Birth Minors Name Minors Date of Birth Homeopathy views health and well-being in a holistic manner. Consultations include a comprehensive intake that carefully evaluates symptoms on the mental, emotional, and physical level. Clients will be asked about their temperament, personal habits, likes/dislikes and unique outlook on life. Providing this information will allow the homeopath to understand each client as an individual and to provide the most appropriate means of care. This view differs from most conventional approaches, which typically limit concerns to the individual symptoms and their treatment. The goal of homeopathic consultation is to strengthen the constitution of the whole person, which results in alleviation of symptoms and an overall increase in health. Shelly Wotton and Wottons Wellness, LLC provide homeopathic/isopathic, and/or personal consultation that may offer increased well-being benefits to the individual. Wottons Wellness, LLC and Shelly Wotton may provide sample remedies for convenience. Confidentiality: I understand that all information disclosed is confidential and may not be revealed to anyone without written permission, except where such disclosure is required by law. Disclosure may be required in the following circumstances: a reasonable suspicion of child or elder abuse or that a client presents a danger to him or herself or to others Office policy I understand that after the initial appointment, follow up appointments will occur every 4 weeks. Questions arising in between follow ups will be responded to as soon as possible during office hours. These communications are intended to resolve brief dosing, administrative and other minor questions. All other new information and questions may be answered during follow up appointments. Please note office hours are: Monday’s and Fridays’ between 9:30am-5pm Eastern Time. Cancellation policy I understand that I will be charged the full fee if I cancel a follow up or an initial appointment less than 24 hours in advance of the appointment. Consent The undersigned gives Informed Consent for the homeopathic/isopathic consultation I, the undersigned, am over 18 years of age. I have read and understood the information above, and I have voluntarily chosen homeopathic care for myself/for my child. Shelly Wotton has answered my questions with \regard to her practice. I understand that Shelly Wotton and Wottons Wellness, LLC is providing solely homeopathic care. I am aware that homeopathic care is not equivalent to care given by a medical doctor and that Shelly Wotton is NOT a licensed health care practitioner. Therefore, it is recommended that I retain the services of my primary care physician for appropriate evaluations and check-ups for myself/my child. I further understand that Shelly Wotton does not diagnose, prevent, treat, mitigate, cure, or prescribe for any particular symptoms, diseases, or conditions. I understand that Shelly Wotton will work to increase my (or my child’s) general vitality and overall constitutional strength. The undersigned acknowledges that Shelly Wotton and Wottons Wellness, LLC do not provide medical, physical rehabilitation or mental health services and do not engage in the maintenance of human health by the prevention, alleviation or cure of disease, involving or reasonably thought to involve an assumption of responsibility for the other person’s physical or mental well-being. Shelly Wotton and Wottons Wellness, LLC do not provide diagnosis, treatment, or the prescription or administration of drugs for the relief of physical disease or mental conditions. Under no circumstances should any suggestions be taken as a diagnosis or direction against a licensed physician or metal health professional. In the event of an emergency concerningme or my child, I am to call 911 immediately, go to the emergency care center and/or contact my physician. The undersigned hereby releases Shelly Wotton and Wottons Wellness, LLC, as well as agents and associates from all claims and liabilities arising from the use or misuse of homeopathic, nutritional and/or wellness modalities, indemnifying and holding Shelly Wotton, Wottons Wellness, LLC and agents and associates harmless from all claims and liabilities therefrom whatsoever. Shelly Wotton reserves all rights. Client Name Client Signature Clear Date Relationship to Client Age Phone Number Email Address Client Information Shelly Wotton, CCH WottonsWellness, LLC Date Name Name of parent if client is under 18 years old: Address: City State Zip Date of Birth Home Phone Cell Phone Best number to reach you : Email address : Date of Birth Age Sex Marital status Occupation Emergency contact person : Phone Referral source: Are you or your child under the care of a physician for the chief complaint you are coming in for? YesNo If yes, please provide the following information: Doctor’s name Phone Do we have permission to contact the doctor if necessary? YesNo Timeline Construct a timeline of your life If you find the process of writing your timeline difficult for any reason, plan to spend no more than 30 minutes on writing it or skip this altogether. It is very important with homeopathy to know your history, as symptoms usually have an “event” which triggered them. Please write all major events in your life from birth to the present day in chronological order along with your approximate date and age you were at the time. If you are filling out this form for a child, create the child’s timeline and mention any unusual trauma, stress or emotions surrounding the mother’s pregnancy. Write the symptoms experienced at moments of trauma or symptoms which you can relate to those traumas. Client Name Date of Birth The end product should be a chronological list of major events in your life, either emotional or physical, including any times when new symptoms appeared or when a deviation of health, such as a lack of energy, etc. was noted. Please be sure to include at least the following: Marriages and Divorses Number of children (if a mother) Accidents (fall off of bike, broken leg, hit with baseball, etc.) Excessive Joys (weddings, surprises) Grief and loss (separated from parents, best friend died, miscarriage, heartbreaks, disappointments, etc.) Surgeries and medical interventions Emotional challenges and interventions Trauma (rape, incest, children in prison, etc.) Diseases/traumas your mother had while she was pregnant with you Other Stress of any kind: work, personal, family Mention any recurring dreams you have had or are having. Please make sure you have at least one page if you are an adult outlining the major events of your life. Call 978-877-3947and book an appointment now.
