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  
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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 *
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.
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