Acute Care Questionnaire
Thank you for contacting Healing Way Homeopathy for Acute Care. To register for an Acute Care consultation, please submit this form. Please submit a SEPARATE questionnaire for each person you are requesting care for. Once your form is submitted I will review your case notes and contact you via phone to provide you with the suggested remedy information. I will respond to your request within 24 hours. IF YOUR REQUEST REQUIRES MORE URGENT ATTENTION, PLEASE SUBMIT THIS FORM AND LEAVE A VOICEMAIL AT 920-740-5048.

Acute Care Fee Schedule
Base Consultation Fees include the questionnaire and communication to gather information and provide instruction. Base fees also include 3 days of follow-up to help assess remedy action and provide support. In the event an acute lasts longer than three days additional fees may apply (see below)

Monday-Thursday until 5pm:
$35 Base Consultation Fee Monday-Thursday after 5pm: $45 Base Consultation Fee

Weekend (Friday 5pm-Sunday) or Holiday: $55 Base Consultation Fee

Remedies:
$15 Per remedy vial obtained through consulting with Healing Way Homeopathy. *Remedies only available through HWH during Regular Business Hours. Remedies also available locally at Vitamin Shop, Free Market and Natural Healthy Concepts.

Additional Fees
$15 for each additional assessment needed past the initial 3 days.

Note: by submitting this form you are requesting acute consulting to be provided and fees will be applied. If you are interested in scheduling a FREE 15-Minutes Informational Phone Call to get your questions answered about my practice you can do that at: https://squareup.com/appointments/book/c10fe739-a01b-40e7-a016-bc2aca47af5d/A0EDRHXDZKW85/services


Email address *
Contact Information
Name *
Your answer
Email and Phone *
Your answer
Acute Questions
Please describe the main concern *
Your answer
What symptoms are present?
Pain, chills, fever, sweat, dry, thirst, heat, appetite? Please be specific and detailed
Your answer
Modalities: What makes the symptoms better or worse?
Cold or heat? Covering or uncovering? Indoors or outdoors? Eating/drinking? Please be specific and detailed.
Your answer
What symptoms are the most bothersome? *
Please be specific
Your answer
What is the worse thing about this for you? How is it affecting you? *
Please be specific
Your answer
What has happened in the days leading up to the concern? *
For example: Big event, stressful or emotional situation, injury, etc
Your answer
How has this affected your a) mood b) sleep c) energy d) life in general?
Your answer
What is the most outstanding emotion present during this?
Irritability, weepiness, anger, apathy
Your answer
Please provide any other information you think would be important for me to know?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms