Internship information

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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

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 *

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.

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