patient history form

If you have not yet been assigned a patient number, please call 207.774.4244 or email our administrator at support@baylighthomeopathy.com. This form takes about 10 minutes to fill out. Do not feel obliged to be too detailed, but please do consider each section so that we do not miss significant pieces of your health history.

Basic Information
If you do not yet have a patient number, please contact Baylight Administrator @ 207-774-4244.
(i.e. chief complaints)
Please explain.
Injuries & Dates
(tooth extractions, braces, etc.)
Hospitalizations & Surgeries
Medications
Include prescriptions, non-prescription meds, herbal remedies, vitamins, supplements, etc. Include dosage and frequency.
Allergies & Sensitivities
Include drugs, foods, chemicals, environmental
Illness & Treatment History
Please include dates & treatment.
Please include dates & treatment.
(sinus, mouth, throat, lungs) Please include dates & treatment.
Please include dates & treatment.
(stomach, liver, intestines, hernia) Please include dates & treatment.
(kidney, bladder) Please include dates & treatment.
(muscles, ligaments, bones, spine) Please include dates & treatment.
(rashes, dryness, lesions, moles) Please include dates & treatment.
Reproductive (female)
Reproductive (male)
PSA
Significant Events
Have you had any of the following?
Please check all that apply
Immunizations
Lifestyle
(how much, how often, # years)
(how much, how often, # years)
(name, how much, how often, # years)
(how much, how often, # years)
(eating habits, food allergies, cravings, preferences)
Family Medical History
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
(age or age when passed, diseases, conditions, traumas, allergies, significant life events)
(age or age when passed, diseases, conditions, allergies)