Loretta Butehorn,Ph.D., CCH
345Neponset Avenue
Boston,Massachusetts 02122
1-617-529-2806
lbutehorn@earthlink.net
www.lorettabutehornphd.com
Homeopathic Intake Form
There is frequently a wait of several weeks so please make appointment BEFORE you begin filling out form. Remember
it is NOT necessary to complete form before appointment. Just do what you can.
NAME:_________________ DOB:_________Today’s date:
_______
Referred by:_______________________
Referral phone:_________
Your Phone:_____________Email:____________________
Address: ______________________________________________
Please call to make appointment as soon
as you receive intake form as there is often a waiting list. Thank you
Everything on this questionnaire is completely confidential. If there are any questions you do not
feel comfortable answering , you may leave blank.
Are you chilly or warm_______? Thirsty or not so?______
CHIEF
COMPLAINT (CC) WHAT BOTHERS YOU MOST
1. What bothers
you most these days (chief complaint CC)_________
2.
At what time of the day or night is the CC the worst? Specify
an hour if you can
_____________________.
3. When did this begin _________?
4.
What was going on in your life when this first
started___________
_______________________________?
5. What
important life events took place in six months prior to problem starting ___________________________________________?
6. What makes you feel better (types of food, weather heat/cold light/noise, anything else you can think
of)_______________________________________?
7.
What is biggest stress in your life right now ____________________
? How do you like to deal with what upsets you: circle all which apply:
Talk Be left alone Not Think About It Take
Action Other_____
8. What do you worry about
_____________________?
9. What is the "craziest” worry have __________________?
10. Give
a numerical rating for each personality trait 0- 10 (with 10 greatest amount.)
a. self
confidence__
b. self critical___
c. jealous___
d. neat___
e. anxious,
worrisome___
f. fearful____
g. down in dumps___
h. critical
of others___
i. easy going_
j. tearful___
k. stoic (strong silent type)___
l. talkative____
m. quiet___
n. shy___
o.
outgoing____
p. spiritual____
q. clairvoyant____
r.
sensuous____
s. enjoys eating___
t.
bored___
u. tired____
v.
hopeless___
w. angry____
x. energetic____
y.
like to be helpful___
GENERAL HEALTH QUESTIONS
10. What medications do you take more than 1x per month _____? What recreational drugs do you use daily
_______ monthly ________ occasionally ________?
11.
How many alcohol drinks do you take a day _______? Have you ever had detox
for alcohol or drug use?____________ Have you ever had an alcohol/drug evaluation?________If so, when________.
12. Do you smoke?________Ever?__________Date stopped?___________Multiple starts and stops please note on back sheet.
13. How well do you sleep (1-10 10 =excellent) _________?
What do you dream
about _______? Do you remember your dreams? _____ What are they about?_____________________________ Do you have recurring
dreams?____ About what____________________________________________________________________________________________________When
you awake how do you generally feel?(refreshed-groggy-tired-etc)__________ Do you typically wake up in the middle
of the night at a particular time?________What time ?________What’s on your mind ?___________What do you do to go back
to sleep? __________How long does it take ?__________
14. Mention
anything else about your physical-mental-emotional state that you are aware of_______________________________________________
15. What other symptoms accompany
your CC?________________________________________
16. What aches-pains-irritations do you have which you might think
“are not worth mentioning?”____________________________________________
MENTAL/EMOTIONAL ASPECTS OF LIFE
17. What are your fears in life? _________ Any other fears (darkness, being alone,
in crowds, altitude, flying, elevators, etc.)?___________________________ What are you most fearful of (real or irrational)_______?
18. Do
you weep easily ______? About what kinds of things_________________________?
19. How do other
people view you? ________________________ What do others complain about in you?_____________
20. How
do you react to stress?____________________________ What is the biggest stress factor in your life now?___________________
21. Are you a tidy person or not so tidy?______ Do you tend to collect things?_____________Do you like
to be on time___________Are you usually early/late________________Why_______________
22. What
bothers you most in other people? ______ How do you react to it?____________________
23. What
do you do for work? _______Are you happy in your work?________ Ideally, what would you like to do?____________
What hobbies, interests or activities do you engage in regularly ?____________________Are there any you
keep thinking you’d like to “take up?”________________
24. If you had
an unexpected week's paid vacation from work, what would you do? _____________________________________________________
25. On
what occasions do you feel jealous? _________________
26.
Are you clairvoyant? _____________________Psychic?
____________
27. Do you think of yourself as a religious person? ____ A spiritual person? ____Say
more about this, please________________________________________________________________________________________________.
28. What
do you do for fun? ________________________________
29. What types of movies do you most enjoy?
__________TV programs? _________Books?_________
30.
How many hours a day do you spend at a computer?______On Internet?_________What
type of Internet sites most intrique?_________Give you most enjoyment?__________
31. If you were going
to a costume ball and had to dress up like a real or fictional character MOST reflective of you, which character might that
be? __________________
PSYCHOLOGICAL
32. Have you been in
counseling before?__________Dates________Issues____________When did you end treatment__________Why__________Did you terminate
with therapist_______________.Please list all dates and issues on back of this sheet for multiple treatments.
33. Where
you ever on any medication for emotional/psychological issues?___________Where they helpful?___________What
was/wasnot helpful___________________________________When did you last take these medications?__________________________
34. Have
you ever been psychiatrically hospitalized?_________ Was this helpful?_________Why/why not?_____________
MEDICAL HISTORY
35. What
medications are you taking at present?_________________________
36. Any TB
or any gonorrhea, syphilis or other sexually transmitted diseases in your history or that of your parents, grandparents, great-grandparents,
etc.? _______________________
37. Family History:
Mention diseases and causes and age of death of parents and siblings. ________________________________________________________________________.
38. Time Line:
A.
Mention from birth on to the present day all important traumas,
both emotional and physical, heartbreaks, divorces, work-related events, surgeries and other physical traumas, diseases or
traumas your mother had while pregnant with you, family stress, death of family members or friends, disappointments, etc.
Also mention positive events such as marriage, birth of children, etc. (Write at end of form for timeline.)
B.
On timeline indicate dates (approximate) of treatment for any
physical or mental/emotional problems (i.e. measles, heart attack, manic depressive episode, outpatient therapy for anxiety,
steroids for allergies etc.)
APPETITE/DIGESTION
39. How you feel after meals?_____________How do you feel if you go without a meal?_______________ Food: cravings for:_________________________Aversions
to (dislike taste,bad reactions to ) _________________________________Describe your diet in a few words:______________________________________________If
you could eat without any health consequences what would you diet be like?_________ Why is that__________________What are
your favorite foods__________?. What food do you dislike____________? Are
you thirsty__________ For hot drinks______cold drinks_________ice cubes_________Do you drink with big gulps or little sips
throughout the day________ Favorite drink_____________ Do you drink coffee?__________If yes,how many cups
per day__________.
40.
Gastrointestinal symptoms after meals:
gas____indigestion_____burping_____bloating?_______Location: above the navel?___below the navel?_____ both?____Bowel movement:
Frequency if you don't use a laxative:_______Frequency of use of laxative_____________.Any problems with urination or
bowel movements__________________________________________________________________
PERSONAL RESPONSE TO ENVIRONMENT
41. What sort of
weather do you dislike most? (damp, cool, hot, windy, etc.) Are you a chilly or a hot person?__________ Or is it difficult
for you to find a comfortable temperature?______________________
42. Are you generally cold
or warm? (circle one) When are you too hot or too cold ?____________
43. How do you react towards sunlight?_________________Do you wear sunglasses a lot?___________________
44. Do you have dry or oily skin? _______________ Is the skin on your face different
from the rest of your body?__________Do you have brittle nails?______________
45. Have
you had any of the following?.
Warts: where
year
treatment
Cysts: where
year
treatment
Polyps: where
year
treatment
Tumors: where
year
treatment
Skin disorders: where
year
treatment
46.
Do you perspire a great deal?____When and where on body? (feet, head, hair,
armpits, etc.)___________________________________
47. Allergies?_______________When____________Symptoms__________Since
what age________
MENSES/PREGNANCIES
48. Menses:
age first began________ time between periods, in days._________
duration_______color/clots________________PMS symptoms__________
49. No.
of pregnancies:_____ no. of children________miscarriages________abortions___
50. Discharges:
post-nasal drip?________vaginal?_________other?________ Color, consistency, time of these discharges_______________________
RESPONSES TO VACCINATIONS AND MEDICATIONS
51. Do you tend to need a smaller doses of medicines than most people? ___________Do
you need less anesthesia than most people?________Do you have a hard time coming out of anesthesia?_________Do you tend to
react to vitamins and herbs and/or need hypoallergenic vitamins?______________
52. Have
you had any vaccinations since the standard childhood ones?__Have you ever had any adverse reactions to vaccinations?_________________________
53. When was your last physical________Any problems then___________________________Treatments given at
that time______________________________________________?
54. What pain do you
experience on any kind of regular basis____________________? Where do you feel pain:left side________right side______both
sides________other description__________. What type of pain is it: burning_______stabbing______aching_____pressure________other________.
How frequently do you have pain (be as specific as possible) AM_____PM_____Upon waking_____Daily_____Monthly______Every
_________? What makes pain better (other than medication, i.e. moving about, eating, etc)_____________What makes pain worse_____________________
Frequency of pain in the month___________.
GENERAL
QUESTIONS
55. How would someone who knows you well describe you__________________________________________________________________________________________________________________________________________________________
56. How would a causal acquaintance describe you _________________________________________________________________________
57. How would you describe yourself________________________________________________________________________________________________________________________
58. What treatment are you currently using for your CC ______________________________________________________________________________________________________________________________
59. Please do not stop any current treatment until homeopathic treatment has
begun to help and you have talked to your allopathic
physician.
60.
What else would you like to tell
me about yourself or your condition that has not been covered in this questionnaire?__________________________________________________________________________________
Please
score for each 1-10 (10 highest) based on how you are feeling TODAY.
1. Quality of life ______
2.
Energy to live my life ___
3. Enjoyment I get out of life______
4. Quality of my intimate relationships____
5. Quality of my friendships_____
6. Quality
of my familial relationships_____
7. General sense of well being_____
8. Belief
my health problems are resolvable______
MOST IMPORTANT QUESTIONS: What aspect
of your current problem is most distressing to you? In other words, specifically how and why is this a problem to you?____________________________________________________________________
What does this problem stop you from doing?_______________________Requires that you do____________________________________________.
Why is this problematic_______________________________________________________________.
Thank you for your time
and attention to this questionnaire. I know it is comprehensive. In homeopathy, it is
very important to choose the correct remedy for you with your particular make-up, rather than gave
a remedy only for the symptoms you are currently concerned with.
If possible, Please mail or e-mail
this in ahead of appointment:
L.Butehorn,Ph.D.,CCH 345 Neponset
Ave Boston,MA 02122
lbutehorn@earthlink.net.