Comfort Care Health History-Tier 2

Comfort Care Health History Form

Step 1 of 6

Date

Client name

First Last

Client phone

Client email

Name of person filling out this form (if not the client)

First Last

Your phone (If not the client)

Your email (If not the client)

Relationship to the client?

How did you hear about HHN Comfort Care?

Strange Rare Peculiar Podcast

Homeopathy Help Now

Academy of Homeopathy Education

International End-of-Life Doula Association (INELDA)

Facebook

Instagram

The Lori Project

Other

Client Information

Date of birth

Age

Height

Weight

Medical diagnosis/stage

What symptoms are you currently experiencing?

Current prescription medications and all medicinal supplements:

Current vitamin/mineral/herbal supplements:

Current use of alcohol, tobacco, marijuana, CBD or other substances (prescribed or recreational)

Recent and/or significant surgeries:

Recent significant hospitalizations:

Fall history, accidents, traumatic injuries, broken bones, etc within the last year:

Medical services current receiving:

Home Health

Hospice

PT/OT

Radiation Therapy

Chemotherapy

Dialysis

Feeding Tube

Other

Please list other medical services used:

Current complementary or integrative therapies:

Acupuncture

Hypnotherapy

Meditation

Reiki

Music/Sound Therapy

Massage Therapy

Guided Imagery

Other:

Please list other alternative therapies used:

Has the client used homeopathy before?

Yes

Has the client worked with a homeopath before?

Yes

If yes, when was the client last seen by a homeopath?

List any homeopathic remedies taken in the past 3-6 months:

Living situation

Independent

Multigenerational Home

Senior Living/Assisted Living Facility

Nursing Home

Hospice

Other

If other, please describe:

What are the goals of homeopathic care during this time? (What symptoms do you want to relieve?)

Primary Caregiver Contact Information (If applicable)

Primary caregiver name:

First Last

Primary caregiver phone:

Primary caregiver email:

Primary caregiver relationship to client:

Healthcare Proxy/POA Contact Information (if applicable)

Healthcare proxy/POA name

First Last

Healthcare proxy/POA phone

Healthcare proxy/POA email

Healthcare proxy/POA relationship to client

If you are the client's healthcare proxy/POA, please upload the client's healthcare directive and/or power of attorney documentation(Required)

Max. file size: 50 MB.

Consent Forms

Consent for homeopathic treatment

I wish to have homeopathy included as part of my end-of-life care. I confirm that I have read and understand the terms of service outlined below, and hereby give my consent for care. If I am completing this form on behalf of a client, I affirm that I am authorized to do so and consent to care on their behalf.

Our work together (Please scroll to read)

• HHN Comfort Care is an initiative of HOHM Foundation and provides access to safe and accessible homeopathy care while engaging in outcomes-based clinical research in conjunction with The Academy of Homeopathy Education.
• Homeopathy views health from a holistic perspective. Homeopaths do not make a medical diagnosis. It is your responsibility to maintain a relationship with a licensed physician or primary care provider for appropriate evaluations and check-ups.
• Under no circumstances should suggestions be taken as a medical diagnosis, nor should recommendations be seen as direction against a licensed medical or mental health care professional’s advice.

By agreeing to HHN’s terms of service you agree to the following:

• I understand that the goal of homeopathy is to increase general vitality and help support the body in its day to day functions. No specific disease will be diagnosed or treated.
• I authorize discussion of my case notes with other homeopaths and/or health care professionals should assistance in remedy selection and/or case analysis be necessary or if my best interest is served by such a consultation.
• I am over 18 years of age and have voluntarily chosen homeopathy care for myself.
• I am aware that the outcome and duration of homeopathy care may vary by individual and cannot be guaranteed, and that the assigned practitioner offers no warranty or guarantee as to the outcome of the homeopathy care.
• I agree that I have a choice with regard to where I obtain the homeopathic remedies recommended.
• This Agreement shall be governed by the laws of HOHM Foundation’s incorporating State of Delaware and the venue of any action brought concerning the interpretation or enforcement of this Agreement shall be proper in the county the practitioner resides.
• The Parties agree that the terms and provisions of this Agreement embody their mutual intent and that such terms and conditions are not to be construed more liberally in favor of, or more strictly against, either Party.
• If any provision herein is invalid, it shall be considered deleted from this Agreement and shall not invalidate the remaining provisions of this Agreement.
• I understand that the homeopath I will be scheduled with is not a medical doctor and does not diagnose or treat disease. All recommendations are for supporting the body only.

In the event of a medical emergency, immediately seek care with your licensed medical provider or Emergency Department.

Research consent

Yes, I consent (or am authorized to consent on behalf of the Client) to allow anonymized clinical information from the Client’s case to be used for research purposes.

No, I do not consent (or am authorized to deny consent on behalf of the Client) to allow anonymized clinical information from the Client’s case to be used for research purposes.

Signature of client or representative

Deposit

A $50 deposit is required to submit your request. This amount will be applied to your consultation fee.

Comfort Care Deposit

Price:

Total

Credit Card

Cardholder Name

Card Details

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Comfort Care Health History Form

Client Information

Primary Caregiver Contact Information (If applicable)

Healthcare Proxy/POA Contact Information (if applicable)

Consent Forms

Deposit

THE INSTITUTE FOR THE ADVANCEMENT OF HOMEOPATHY

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HOHM RESEARCH