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Acute Care Request Form

Homeopathy For Women
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Acute Care Prescription Request Form

Acute Care is provided in the USA and Canada Only.
Homeopathy is NOT Urgent Care! For urgent or life-threatening issues, call your doctor, medical practitioner or 911 now.

Conditions lasting 30 days require Chronic Care -  request Chronic Care here.

PLEASE READ THIS BEFORE SUBMITTING THE FORM.

We DO NOT accept acute requests if the client has already started any prescription drugs, including steroids, inhalers, antibiotics and/or is currently hospitalized.
Medical insurance does not cover our homeopathic services.

Only Submit Acute Care Request on Monday - Thursday 9 am - 3 pm (PST).
We do not reply to requests submitted after business hours, on all Fridays, weekends or legal holidays.

Returning Acute Care Clients must have access to a 200C remedy kit for care.

ACUTE CARE FEES

  • Basic Acute Care: $75 per person, per acute for 7 days of consecutive care by email.

  • Sport Injury Acute Care: $120 per person, per acute for 7 days of consecutive care by email.

  • Infectious Disease Acute Care: $150 per person, per acute for 7 days of consecutive care.

  • Infectious acutes specifically include: whooping cough, meningitis, MRSA, pneumonia, staph infections, strep throat and other serious infectious diseases.

  • Care is available for women, men and children by email for short term, non-life threatening illnesses like: fevers, chills, colds, flu, coughs, vomiting, diarrhea, earaches, teething, back pain, sports injuries, etc.

  • Acute care includes the initial acute intake, cases analysis, acute remedy prescription(s) and any required remedy or potency changes during the acute for up to 7 consecutive days.

  • An extension of 7 consecutive days of Acute Care is available at an additional $75 per week ($150 per week for infectious disease care) and can be renewed as needed up to 3 additional weeks.

  • Acute illnesses lasting more than 4 weeks are considered chronic care

  • Chronic care fees will apply if ongoing care is requested.

  • Fee does not include any of the homeopathic remedies needed.

  • Repeat Acute Care clients are required to have fast access to a Home Remedy Kit of 50 acute remedies in a 200C potency for optimal care.  Order a home remedy kit here!

WHAT ACUTE FEES COVER

  • Acute Care fee covers and specifically includes: initial case analysis, prescribing the remedy(ies) needed during this acute, all email correspondence related to this acute and email follow-ups as needed on a daily basis until this acute is handled OR up to 7 days, whichever comes first.

  • Additional acute care requested past 7 days is paid in advance via Paypal at the same rate.

  • Acute care may be extended for up to ONE (1) month maximum before converting to chronic care.

ALL ACUTE COMMUNICATION IS BY EMAIL

  • You will be asked to report by email on a daily basis or as instructed during acute care.

  • This will help the Homeopath to determine a remedy's effectiveness and/or prescribe a new remedy, potency, dosing changes until the acute is over.

ACUTE CARE AND HOMEOPATHIC REMEDIES

  • Your Acute Care Fee does not include the cost of any remedy(ies) that are prescribed. 

  • It is the client's responsibility to obtain the remedies prescribed either at your local pharmacy or health food store or on-line as fast as possible.

  • You may order a remedy kit here: 200C Remedy Acute Kit for $149 plus $16.50 shipping and handling.

  • Dry remedies in a remedy packet of 4 - 8 pills ordered from the Homeopath for $10 per remedy potency, including mailing in the USA.

  • Express mail shipping and handling is an extra fee based on the actual cost.

All fields are required to submit this Form.
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ACUTE  CARE SYMPTOMS FORM

THIS FORM TAKES 10 MINUTES TO COMPLETE. TAKE YOUR TIME!
ALL FIELDS MUST BE COMPLETED IN ORDER TO SUBMIT.

Your information about acute symptoms will give us the specific details needed to quickly prescribe the right homeopathic remedy.

You will receive a copy of all symptoms submitted and other instructions about homeopathic care by email immediately after submission of this form. 

IMPORTANT: If you do not immediately receive a copy of this form after you submit it by email, it means that your submission was NOT successful and we have not received it.  Review it again, checking that all fields are completed.

ACUTE CLIENT INFORMATION

First and Last Name

First and last name of person submitting form

Email

Email of person submitting this form.

Check for accuracy! This form will only submit with a valid email address.

Name of Person for Care
Age of Person for Care
Date of Birth for Person for Care
Month, date, year
Your Complete Mailing Address: Include all: Address, City, State, Zip Code.
Phone(s)

Please provide your home, work, and/or cell phones.

Skype address If none, write N/A. 
Best Time(s) To Call Please provide best times to call, if we need to reach you by phone.
Have you ever used homeopathy before? If YES, please give the NAME of your most recent Homeopath below.


If NO name of recent homeopath or never used homeopathy before, write N/A.

TYPE OF ACUTE

What is the GENERAL LOCATION of where this acute is located?

Select one LOCATION that is the best match for the major issue and it's symptoms.

What is the MAIN ISSUE for this acute?

Select only one MAIN ISSUE that is the best match.

Please briefly describe this acute.

Give us the basic details for this acute.

ONSET OF THIS ACUTE

Onset of this Acute

Select only one for ONSET.

What happen JUST PRIOR to the time this acute began? Describe what happened briefly just PRIOR to this acute if an illness.
For example,
was there any change in weather? Change in sleep?  Exposure to sick family members?
Other illness?  Emotional trauma?
Physical trauma? Include the types of circumstances involving the mind and the emotions.

Briefly write about what you think might be a "Trigger" Event that happened in the last 48 hours up to one week prior to this acute in not an accident or injury.

MENTAL/EMOTIONAL SYMPTOMS

Mental and Emotional Symptoms

 

Has the person's CURRENT STATE OF MIND OR EMOTIONS changed from how they usually are? Select only one.

What is the general state of MIND OR EMOTIONS of the person now?
Select only one that is the best match.

Add details needed to clarify the CURRENT STATE OF MIND.  Include if there are CHANGES in the general mood from the normal mood with this acute.

If none, write N/A.

ENERGY LEVEL AND MENTAL/EMOTIONAL SYMPTOMS

Describe current ENERGY level Select only one for ENERGY LEVEL.

FEVER OR CHILLS

Are FEVER or CHILLS present right now? Select only one for FEVER OR CHILLS.  Report is what the body temperature is NOW.

If there were FEVER or CHILLS present in the last 48 hours, give the actual temperature now or write about any chills.

If none, write N/A.

THIRST

How THIRSTY is the person now? Select only one for THIRST.

PERSPIRATION

Describe the PERSPIRATION.

Select only one on for PERSPIRATION.

COUGH

Is a COUGH present? Select only one for COUGH.


What type of cough best describes it?
Select only one.

If there is EXPECTORANT (MUCUS) with the cough, describe the color such as clear, white, yellowish, greenish, bloody, etc.

If none, write N/A.

NOSE MUCUS

Is NOSE MUCUS present? Select only one for NOSE MUCUS.


What is the COLOR AND CONSISTENCY of the nose mucus?
Select only one that best describes it.

THROAT

Is a SORE THROAT present? Select only one for THROAT.

What SIDE of the throat is affected?
Select only one.

STOMACH

Are there any issues with STOMACH? Select only one for STOMACH.

Describe any current STOMACH issues below.  Include any changes in food desires, food aversions, any discomfort, any VOMITING and how often, etc.

If none, write N/A.

STOOL

Are there any issues with STOOL? Select only one for STOOL.

Describe any current STOOL related issues below.  Include if any DIARRHEA, LOOSE STOOL or CHANGES IN STOOL for this acute.  If STOOL has changed describe the frequency, color, consistency and odor. 

If none, write N/A.

SKIN

Are there any SKIN issues present? Select only one for SKIN.

Describe any SKIN issues below.  Include color discoloration such as red cheeks, red ears, pale, etc.  Describe how it looks, any dryness, if itching.  Tell what makes it feel better or worse, etc.

If none, write N/A.

SIDE OF BODY AFFECTED

What SIDE of the body in general is most affected?

Select only one for SIDE AFFECTED.

TIME  KEY SYMPTOMS ARE BETTER

What time of day are the symptoms Better?

When are the key symptoms Better?
Select only one.

TIME KEY SYMPTOMS ARE WORSE

What time of day are the symptoms WORSE

When are symptoms WORSE?
Select only one.

Time When Feeling Better or Worse

Describe any TIME OF DAY issues below regarding when a symptom or set of symptoms are Better or WORSE.

If none, write N/A.

WHAT MAKES THE KEY SYMPTOMS FEEL BETTER?

What makes the person and/or the symptom feel Better?

 

This is one of the most  important questions to selecting the right remedy!

WHAT MAKES THE MAIN ISSUE FEEL Better (ameliorates)?

WHAT MAKES THE PERSON FEEL Better? being carried/held (infants young children, being quiet, being left alone, fresh air, dark room, fresh air, lying still, rest, sleep, movement, etc.

Heat: hot applications, warm drinks, blankets, warm drinks, etc.

Cold: cold applications, cold drinks.

Food:  eating, not eating, etc.

If so, describe using items above and others that apply. 
If none, write N/A.

WHAT MAKES THE KEY SYMPTOMS WORSE?

What makes the person and/or symptom feel WORSE? This is one of the most important questions to selecting the right remedy!

WHAT MAKES THE MAIN ISSUE WORSE? (aggravates).

WHAT MAKES THE PERSON FEEL WORSE?
Noise, exertion, movement, lying down, sitting, standing, sunlight, touch,
pressure, no pressure,  etc.

Heat: hot applications, warm drinks, blankets, warm drinks, etc.

Cold: cold applications, cold drinks, etc.

Food:  eating, not eating, etc.

If so, describe using items above and others that apply. 
If none, write N/A.

EXTENSIONS

Does the pain or discomfort EXTEND to any other part of the body?

Give any EXTENSIONS FOR MAIN ISSUE.

For example:
pain from the left to the right from the top to bottom
from the head to the neck
from the shoulder to the back

If so, describe. 
If none, write N/A.

SENSATIONS

Are there any SENSATIONS that describe the feeling, pain, etc. of this acute? Give the primary SENSATION FOR THE MAIN ISSUE.

If the sensation for the primary issue is not in this list, please write it below. 
If none, write N/A.

UNUSUAL, STRANGE, RARE OR PECULIAR SYMPTOMS

Are there any UNUSUAL, STRANGE, RARE or PECULIAR (SRP) symptoms present now? This is another very important questions to selecting the right remedy!

Include any UNUSUAL, STRANGE, RARE OR PECULIAR SYMPTOMS FOR THIS PERSON. This would be things rarely or never seen  that appear now with this acute.  Include things like strong changes in emotions, stool and color changes, unusual food desires, unusual tastes,  sounds heard differently, strange noises made, uncontrolled body movements, skin discolorations, strange behaviors, etc.

If so, describe. 
If none, write N/A.

OTHER TREATMENT SO FAR

What other TREATMENT was given for this acute? Include any OTHER TREATMENT being done now.

HOMEOPATHIC REMEDIES TAKEN:
a. Include any homeopathic remedy and potency taken for this acute in the last 7 days.

OTHER MEDICATIONS:
Include any over the counter OR prescription medication that was taken for this acute in the last 7 days.

ADDITIONAL COMMENTS

Homeopath Requested for Acute Care

Choose one Homeopath from options below:

Please add any other COMMENTS here.

Include any other COMMENTS here. 
If none, write N/A.

How did you find out about Homeopathy For Women?

Select only one.

Were you REFERRED to us?

If you are a REFERRAL, please give the name of the person who referred you.
If were were not referred by someone, write N/A.

Please review your Acute request carefully for accuracy and completeness before submitting it.

All fields must contain answers for this Acute Form to submit, including if they are not applicable, write N/A.

Your information is always kept private and confidential.

By submitting this Form, you give Homeopathy for Women and/or any of its Associated Homeopaths
permission to contact you by phone, skype and/or email.  You will be contacted as promptly as possible.

A confirmation screen will appear after your successful submission for you to make your Paypal payment.

You will also immediately receive a confirmation email with specific additional instructions
sent to the email address used in this form.

If you do not receive this email, you did not successfully submit this form.  Review it and try again.

IF YOU CAN'T SUBMIT THIS FORM:

1.  Refresh your browser. 
2.  Check again that ALL the fields are completed especially those in yellow.
3.  Check that you used the exact verification code.

If you still have technical difficulty submitting this Form, email all the data for all the content fields above as requested, in order.
Send the email to tech @ HomeopathyForWomen.org

Please submit this report only once.

Thank you!

This Acute Care Form is copyrighted 2008 - 2016 by Kari J. Kindem, CFHom, CHP, Classical Homeopath, Homeopathy For Women. 
All rights reserved.  No part of this Form or the on-line reporting system may be copied, reproduced digitally or in print without our written permission.




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