Acute Homeopathic Care, Homeopathic Acute Care, Acute Care, Acute Care with Homeopathy

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ACUTE CLIENTS: ACUTE SYMPTOMS FORM
The information about acute symptoms that you provide and in the detail requested will give us the specific information needed to RAPIDLY prescribe a well matched homeopathic remedy. A remedy prescription and dosing instructions will be emailed to you as soon as possible after your $50.00 payment in Paypal has been received. You will receive a copy of all symptoms submitted and other instructions about homeopathic care by email immediately after submission of this form. Submit 1 form per person, per acute injury or illness.
ACUTE CLIENT INFORMATION
First and Last Name
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Name of Person for acute care
Age of Person for acute care
*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, write N/A.*
TYPE OF ACUTE
What is the GENERAL LOCATION of where this current acute is located?	Please select one LOCATION that is the best match for the major issue and it's symptoms.
What is the KEY ISSUE for this acute?	Please select only one ISSUE that is the best match.
Please briefly describe this acute.
ONSET OF THIS ACUTE
Onset of this Acute	Please select only one for ONSET.
What happen JUST BEFORE this acute began?	Describe what happened briefly just PRIOR to this acute if an illness. For example, was there any change in weather? 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 24 hours up to one week prior to this acute.
MENTAL/EMOTIONAL SYMPTOMS
Mental and Emotional Symptoms	Has the person's CURRENT STATE OF MIND OR EMOTIONS changed from how they usually are? Please select only one. What is the general state of MIND of the person now? Please 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
Describe current ENERGY level	Please select only one ENERGY LEVEL.
FEVER OR CHILLS
Is a FEVER or are CHILLS present right now?	Please select only one for FEVER OR CHILLS. Report is what the body temperature is NOW. Explain if there were FEVER or CHILLS present in the last 48 hours. If a fever, give the highest temperature in the last 48 hours. If none, write N/A.
THIRST
How THIRSTY is the person now?	Please select only one for THIRST.
PERSPIRATION
Describe the PERSPIRATION.	Please select only one on for PERSPIRATION.
COUGH
Is a COUGH present?	Please select only one for COUGH. What type of cough best describes it? Please select only one. If there is EXPECTORANT with the cough, describe the color such as clear, yellow, green, bloody, etc. If none, write N/A.
NOSE MUCUS
Is NOSE MUCUS present?	Please select only one for NOSE MUCUS. What is the COLOR AND CONSISTENCY of the nose mucus? Please select only one.
THROAT
Is a SORE THROAT present?	Please select only one for THROAT. What SIDE of the throat is affected? Please select only one.
STOMACH
Are there any issues with STOMACH?	Please 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?	Please 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 changes describe the frequency, color, consistency and odor. If none, write N/A.
SKIN
Are there any SKIN issues present?	Please select only one for SKIN. Describe all SKIN issues below include color, how it looks, any dryness, if itching, and 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?	Please select only one for SIDE AFFECTED.
TIME FEELING BETTER OR WORSE
What time of day are the symptoms BETTER?	When are symptoms BETTER? Please select only one.
What time of day are the symptoms WORSE	When are symptoms WORSE? Please select only one.
Time Feeling Better or Worse as Related Symptoms Described	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 PERSON 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! Include things that make it BETTER like: being quiet, being alone, getting attention, warm blankets, warm drinks, cold applications, cold drinks, eating/not eating, pressure/no pressure, dark room, fresh air, lying still, rest, sleep, movement, exercise, etc. If so, describe. If none, write N/A.
WHAT MAKES THE PERSON FEEL WORSE?
What makes the person and/or symptom feel WORSE?	This is one of the most important questions to selecting the right remedy! Include things that make it WORSE like: noise, movement, lying down, heat, warm drinks, hot applications, cold applications, cold drinks, eating/not eating, sunlight, talking, toucvh, pressure/no pressure, exertion, movement, etc. If so, describe. If none, write N/A.
EXTENSIONS
Does the pain or discomfort EXTEND to any other part of the body?	Give any EXTENSIONS for key symptoms. 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, etc. If so, describe. If none, write N/A.
SENSATIONS
Are there any SENSATIONS that describe the feeling, pain, etc. of this acute?	Give any SENSATIONS for key symptoms. For example: ticking, itching, prickly, hot, burning, stinging, throbbing, tingling, boring, ripping, lumpy, etc. If so, describe. If none, write N/A.
UNUSUAL, STRANGE, RARE OR PECULIAR SYMPTOMS
Are there any UNUSUAL, STRANGE, RARE or PECULIAR (SPR) symptoms present now?	This is one of the most 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 all homeopathy taken for this acute and/or in the last 7 days. b. Give the potency per remedy. c. Give doses per remedy (wet or dry)*OTHER MEDICATIONS:* Include any over the counter OR prescription medication that was taken for this acute in the last 7 days.
ADDITIONAL COMMENTS
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?*	Please select only one.
Were you REFERRED to us?	If you are a REFERRAL, please give the name of the person who referred you. If not, write N/A.
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