Thank you for choosing Dr Dee for your holistic wellness journey. To ensure we can provide the most personalised and effective care, we kindly ask you to complete this intake form thoroughly.

Please take your time and answer all questions to the best of your ability. Consider this an opportunity to share your health history, goals, and any specific concerns you may have. The more information you provide, the better Dr Dee can understand your unique needs and tailor a treatment plan that aligns with your wellness goals.

Please grab a cup of tea, get comfortable, and let's begin!

Contact Details:

First Name *

Last Name *

Phone *

Address *

City *

State *

Postal code *

Email *

Personal Details:

Date of birth *

Country of Birth *

Marital Status *

Number of Dependants *

Name of Doctor & Medical Office *

Occupation *

Employer *

Emergency Contact Details:

Emergency Contact Full Name *

Emergency Contact Phone *

Relation to You *

Medical History:

Major complaints in order of importance to you *

What medications are you currently taking? *

What nutritional supplements are you currently taking? *

What other treatments or therapies are you following, including conventional medical treatments, alternative therapies, or self-care practices? *

Have you experienced any past health conditions, injuries, or surgeries that you believe still affect your health today? If so, please list them. *

Please list any surgeries you have had in the past. *

Do you have any allergies? If so, please list them. *

Can you identify past events or circumstances that may have contributed to your current health conditions? *

Did you have any adverse reactions? If yes, please describe. *

Family Health History:

Please list age (if alive), age of death (if deceased), ailments they experienced, cause of death (if deceased).

Father *

Mother *

Brother/s *

Sister/s *

Children *

Paternal Grandfather *

Paternal Grandmother *

Paternal Uncles/Aunts *

Maternal Grandfather *

Maternal Grandmother *

Maternal Uncles/Aunts *

Your First Homeopathic Appointment:

Reporting Symptoms

Determining the proper homeopathic remedy involves investigating and evaluating all the subjective and objective symptoms you are experiencing in the context of your physical symptoms, individual life circumstances and environment.

To develop an accurate picture of your circumstances and to make our time spent in consultation most effective, please consider and keep in mind the following requests for information as in-depth and accurately as possible. If you have any questions, feel free to contact me.

1. Think about, in detail, the onset of your symptoms. Are there any related mental, emotional, or physical symptoms, and are there any external condition(s) that may have contributed to your state of being at that time?

2. Think about all previous illnesses. Include any childhood diseases and, if applicable, any lasting effects from these ailments. Were any extensive therapies employed in the healing of these conditions? Did you have any reactions or long-term side effects to any such therapies?

3. Think about the symptom(s) you are experiencing in terms of location in the body. Does this symptom shift from one place in your body to another? Are there related symptoms elsewhere in the body? Particular sensations associated with the symptom? How does it feel, look, smell, taste? Is there anything that makes the symptom unique, striking or unusual? If pain is involved, think about the pain you endure, e.g. a dull ache vs. a sharp stabbing pain, a constant or periodic pain, etc. Think about the onset of your pain: slow vs. sudden? How intense is the pain?

4. Make note of when your symptoms feel better or worse: time of day, when you are hot or cold, hot or cold compresses, months, seasons, before or after eating, sleeping, moving, resting, certain positions, when occupied, specific mental/emotional states. Experiment with heat or cold, warm rooms or fresh cool air, warm or cool bathing. Do you notice any difference in the symptom(s)?

5. Are you affected in any way by different kinds of weather? Dryness, humidity, approaching storms, thunderstorms, frost, cloudiness, low or high altitudes, or being by the seashore.

6. Urination (if of concern): Colour, odour, sediment, quantity, frequency, urgency.

7. Stool (if of concern): The number of stools per day, their colour, odour, hard, dry, large, pasty, bloody, frothy, slimy, thin, watery, slender, flat, difficult or incomplete, or urging without stool.

8. Menses: Length of cycle, length of period, significant pain associated with menses, length of period, nature of the flow, clotting cramping PMS, mood swings, bloating, swollen tender breasts, cravings, vaginal discharge with or without menses.

9. Sex: Desires, aversion, painful intercourse, vaginal dryness, impotence.

10. Perspiration: Profuse, scanty, odour.

11. Body Temperature: Hot vs. cold body type, hot or cold hands or feet, hot flashes.

12. Sleep: Do you wake up at night? When? Why? How do you feel in the morning upon rising? What position do you sleep in—side, back, front? Are parts of the body covered or exposed to sleep? Do you have recurring dreams in your sleep? Are there any prominent themes to your dreams? Do you have night terrors?

13. What motivates you in life? Are there lasting traits from childhood that are still an issue today? Are there running themes in your life? For example, "All my life I've been..." How would others describe you? How do you deal with change in your life? Do you need structure in your life?

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If you don't see a 'Thank You' page after clicking 'Submit', it means there might be some missing information we need. We've highlighted those sections in red for you to easily review and complete. Once everything is filled out, feel free to hit submit again!