Patients Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Best Phone for Contact
(###)
###
####
Present M.D. & Phone Number
Medications your child is currently taking
Select he following conditions your child has had
Major Complaints in Order of Importance (since when have they occurred?)
Are there any of the preceding conditions after which your child has not been totally well again? Which ones?
Any Major Operations/Injuries? (Please note when and if there were complications)
Other Major Conditions Not Listed:
Vaccination History:
Measles
Mumps
Rubella/German Measles
Chicken Pox
Whooping Cough
Meningitis
Hepatitis B
If Yes to any of the above, please list any adverse effects from these vaccinations:
Previous pregnancies by natural mother, miscarriages or complications?
Mother’s age at child birth
Mother’s Health during Pregnancy? List any bleeding, nausea, illness, physical or emotional trauma, hypertension, diabetes, medications, alcohol, drug, cigarette consumption, etc
Mother
Father
Brothers
Sisters
Children
Maternal Grandmother
Maternal Grandfather
Maternal Aunts/Uncles
Paternal Grandmother
Paternal Grandfather
Paternal Aunts/Uncles
Which of the following ailments, or any other major ailments, have affected your relatives:
Birth History (Select 1)
Full Term
Premature
Late
Weight At Birth
Length of Labour
Complications During Labour
Age your child began: Sitting
Age your child began: Crawling
Age your child began: Walking
Age your child began: First Words
Feeding: Breast Fed & How Long?
Feeding: Formula (Milk/Soy/Other)?
Food Intolerances?
Age Began Solid Foods?
Is there any other information that I need to know?
Have you received the Covid-19 Vaccine?
Have you received the Covid-19 Vaccine?
Date of 1st Shot
MM
DD
YYYY
Date of 2nd Shot
MM
DD
YYYY
Date of 1st Booster
MM
DD
YYYY
Medical/Professional Waiver
PLEASE READ THE FOLLOWING CAREFULLY (if under 19 years of age, a parent or guardian must sign.) I, the undersigned, understand that Kirsten McGregor is a homeopathic practitioner of classical homeopathy and not a licensed medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. In consulting with Kirsten Mcgregor, I am exercising my right to choose an alternative method of treatment through which to address my total health. As homeopathy is not covered by the existing government medical insurance plan, I agree to pay all fees presented in the current rate schedule. I acknowledge that all personal information will be kept confidential.
In signing below, I confirm that this e-signature is a legally-binding true signature.
Date of Signature
MM
DD
YYYY
