Questionnaire for Clinic Please fill out this form as accurate as possible. This should take around 5-10 minutes Step 1 of 5 20% Name(Required) First Last Email(Required) Phone(Required)Company (if applicable)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country GenderMaleFemaleOtherDate of Birth DD slash MM slash YYYY Occupation Height Weight Emergency contact details First Name Last Name Relationship Email Phone What is your current diet?Do you have any current health problems?If so, How long has this been a problem?Have you had any surgery done?If so, what year did this take place? DD slash MM slash YYYY Please detail any surgery complications if anyPlease detail any recent HospitalisationsPlease detail any medications you are currently taking (incl. hormone treatments, supplements etc.)Did you have a covid vaccine?(Required)YesNoWhich covid vaccine did you have? How many booster shots did you recieve? What year did you receive these? Have you experienced any adverse reactions since your vaccinations? Are you pregnant or think you may be? Yes No PLEASE CHECK ANY PRESENT ISSUES & ANY IMPORTANT PRIOR ILLNESSES Anaemia/blood disease Arthritis Asthma Back or neck problems Blood in stool Bruise easily Cancer Cardiovascular disease Chronic cough Clot in veins Corona Virus previously or present Crohn's/Colitis Constipation Depression Diabetes Diarrhoea Dizziness, fainting Eating disorder Epilepsy Excessive worry Eye trouble Fatigue Frequent anxiety Gain/loss of weight Gall stones Gallbladder problems Gas or bloating Headache Heart problem PLEASE CHECK ANY PRESENT ISSUES & ANY IMPORTANT PRIOR ILLNESSES Haemorrhoids Hepatitis Hernia High blood pressure High cholesterol HIV/Aids Hypoglycemia Intestinal problem Jaundice Kidney problem Liver disease Measles Migraine headache Mononucleosis Multiple Sclerosis Muscle cramps Nervousness Obesity Pain in chest Palpitations Phlebitis Pneumonia Pregnant (currently) Psychiatric problem Pseudoatrophy Rheumatic fever Scar problems Sensitive skin PLEASE CHECK ANY PRESENT ISSUES & ANY IMPORTANT PRIOR ILLNESSES: Sinus/nose problem Shortness of breath Skin problems Sleep problems Stomach problems Swollen glands/lumps Swollen joints Throat problem Thyroid disease Tuberculosis Tumour, Cyst Ulcer Varicose veins Venereal disease Vision problem Women Birth control pills Breast problem Excessive flow Irregular periods Pregnancy problems Vagina/uterus problem Men Prostate problem Testicle problem Please explain any issues or illnesses you checked aboveDo you smoke? If so, How often? Do you use recreational drugs? If so, Which and how often? Do you drink Alcohol? If so, How often? Do you drink Coffee? If so, How often? How much water do you drink each day? Do you exercise? Yes No If so, How often? Is there anything else you wish to share?Consent(Required) AcknowledgmentMedical Policy: I understand that my health and medical history and information is strictly confidential and used only for Naturopathic medicine assessment purposes only. We would like to take this opportunity to thank you for allowing us to shine some light on your path to health and happiness Awaiting you in good health and an open heart.
