Acute Homeopathic Care Detailed Form

ACUTE CLIENTS: ACUTE SYMPTOMS FORM
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. Submit 1 form per person, per acute injury or illness. All fields are required to submit this form.
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
*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 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 when 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 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
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.
SENSATION
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:
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 none, write N/A.
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