Acute Care Consultation — The Butterfly's House

1 Patient Information

Full Name

Date of Birth

Today's Date

Phone

Email

Age

2 Chief Complaint

Describe the acute issue in your own words

Onset

Sudden Gradual

When did it start?

Duration so far

Location of pain / discomfort

What makes it worse? (Aggravations)

What makes it better? (Reliefs)

3 General Symptoms

Temperature Preference

Craves Heat Craves Cold No Preference

Sleep

Restless Excessive Normal

Fever / Temperature

Other general observations (perspiration, discharges, unusual symptoms)

4 Relevant History, Medications & Allergies

Related past conditions or injuries

Current medications, supplements & OTC remedies

Homeopathic remedies already tried for this complaint

Known allergies (medications, foods, environmental)

5 Authorization & Signature

I certify that the information provided is accurate and complete to the best of my knowledge. I understand that homeopathy is a form of complementary wellness support and does not constitute the diagnosis, treatment, or cure of any medical condition.

Client / Guardian Situation

Client Legal Guardian Parent

Client / Guardian / Parent 1 (Required)

Printed Name

Relationship

Date

Signature

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Client / Guardian / Parent 2

Printed Name

Relationship

Date

Signature

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