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 EZY Script (free online health evaluation)

Looking to purchase a prescription only supplement and don’t have a script?  No problem

Simply fill in our free online health evaluation and our online Naturopath will call or email you to approve your  EZY script! (Please turn around time for a response in 24-48 hours). Once your EZY Script form has been received and approved, please upload this as your script when you purchase your product. Your EZY script approval is for Integrated Health Store only and cannot be used to purchase on another site.

Please note this service is for script refills or symptomatic recommendations only, for complex health conditions it is recommended you book a consultation with our Naturopath to ensure your health gets the necessary attention it deserves!

    Surname*:

    Given Names*:

    Date of Birth*:

    Age*:

    Sex*:

    MaleFemale

    Address*:

    Suburb*:

    Post Code*:

    Phone:

    Bus:

    Mobile*:

    Email*:

    Best contact for confirmation of appointments:

    TextCallEmail

    Marital Status:

    SingleDefactoMarriedDivorcedWidow

    Children?

    YesNo

    If so how many?

    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?*

    If so what are you taking?

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

    What are you taking and what dose?

    Do you have any known Allergies?

    YesNo

    What type?

    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)

    HeadEyesEarsNoseMouthThroatChest & Respiratory ChestCardiacCirculation problemsMusclesJointsSpineReproductive organMenstruationUrinary bladderNeurological (nerve) digestionBowelGallbladderKidneysLiver

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

    DiabetesCancerHeart diseaseArthritisHigh /low blood pressureHIV AIDSOr other please specify

    Do you use recreational drugs/alcohol, cigarettes?

    How much caffeine do you consume?

    Do you exercise?

    YesNo

    Please specify what type how often?

    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?

    Signature:Use your touch screen or mouse to sign

    Date:

    Print name*:

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