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Client Follow Up Form

General Instructions:

This form is to be used after the client’s consultation, and for all submitted case updates.

Note: The first seven items below that have a yellow background are required information.

1. Date of Report:   Format: MM/DD/YYYY
2. Client's First and Last Name:  
3. Email Address:
 
4. Remedy and Potency:
- e.g. Nat Mur 30C
 
5. Date(s) remedy was taken:   Format: MM/DD/YYYY
6. Remedy Preparation:
- e.g. 1 remedy pill dissolved in 4 oz of water
 
7. General Results:  
  Much Worse
  Slightly Worse
  No Improvement
  Slightly Improved
  Much Improved

8. Mood, Energy, Sleep:
- Describe in general

 

9. Dreams:
- Vivid or recurring dreams; night terrors

 
10. New Symptoms:
- Never had before
 
11. Returning Symptoms:
- Old symptoms coming back
 
12. New Events:
- Physical or emotional stress or excitement
 

13. Medications:
- New or changes in existing

 
14. Additional Comments:

 
     
Please review carefully for accuracy and completeness before submitting this report.

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