Surname*:

Given Names*:

Date of Birth*:

Age*:

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Best contact for confirmation of appointments:

Marital Status:

Children?

Occupation:

Who is your family GP?

Do you see any other health practitioners?: (chiropractor, Specialists etc):

Have you ever consulted with a Naturopath or Natural Medicine Practitioner before?, if so when?

Do you take any Medication?*

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Do you take any supplements? (vitamins, herbs etc)*

YesNo

Do you have any known Allergies?

What is your main health concern?*

How long have you had this problem?

What makes symptoms better or worse?

What prescription supplement are you wanting a script for?

When did you last feel well?

Do you have any problems in any of the following areas? (please select)

Have you had any of the following diseases diagnosed? (please select)

Do you use recreational drugs/alcohol, cigarettes?

How much caffeine do you consume?

Do you exercise?

How much stress do you have? Scale of 1-10

Do you sleep well?

How many hours?

How is your energy? Scale of 1-10

What is your blood type?

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