Internship information
Thank you for participating in the internship! That is greatly appreciated.

Please provide us with some information so we can create a patient file. Thank you for the effort.

Kindest regards,
Educational Center for Classical Homeopathy  
Sign in to Google to save your progress. Learn more
Email *
First name *
Family name *
Gender *
Address *
Please fil in the name of the street where you live and the house number.
City *
Zip code *
Country *
Phone number *
Date of birth *
MM
/
DD
/
YYYY
Medication *
List all the medication or supplements you might use. Write n/a when you do not take medication or supplements.
Family health *
Please list the health issues that run in the family. E.g.: Father: migraines, heart attack. Mother: psoriasis. Grandfather: Tuberculosis, depression.
Fever *
Describe the approximate frequency of fever and other acute complaints. Some examples: about once every two years a fever + once or twice every year a severe cold, last fever was 10 years ago, never have fevers but do have some colds once in a while.
Name intern *
What is the name of the person (student) who is going to treat you during the internship?
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Opleidingscentrum Klassieke Homeopathie. Report Abuse