Consultation form

Contact Info

Name *

First

Last

Age *

Date of Birth *

Gender *

Male
Female

Email *

Contact Number

Occupation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Your Main Health Goal/Concerns *

How long have you had it? *

Describe any factors you suspect may have played a role in the onset and prepetuation of your condition:

Have you had any consultations from other practitioners before?

No
Yes

Please list any other health concerns or goals in order of importance:

How would you describe your general state of health? *

Excellent
Good
Fair
Poor

Past Medical Conditions:

Allergies and/or food sensitivities if there are any

Current medications/supplements:

Please list any other illnesses if they are not listed above:

How would you describe your appetite?

How many meals do you eat per day?

How often do you eat?

Do you ever have indigestion after eating or stamch pain, discomfort, nausea, vomiting? If so, please describe:

Do you eat dairy products?

Yes
No

Do you eat meat?

Yes
No

Were you given antibiotics as a child?

Yes
No

Do you avoid any foods?

Do you feel thirst easily?

Yes
No

How much liquid do you drink per day?

Which do you prefer for your drinks?

Cold Drinks
Hot Drinks

How many bowel movements do you have per day?

At what times do you have these bowel movements?

Do you suffer from the following conditions?

Gas
Bloating
Bad Breath

How often do you urinate per day?

Do you have:

Profuse Urine
Scanty Urine
Interrupted Flow

Do you feel difficult to urinate?

Yes
No

Do you feel pain while urinating?

Yes
No

What colour is the urine?

Clear
Light Yellow
Dark Yellow
Other

Do you wake up during the night to urinate?

Yes
No

Do you feel that you have enough enegery during the day?

Yes
No

What time during the day do you feel you have the most energy?

What time during the day do you feel you have the least energy?

How easy is it for you to fall sleep?

Do you wake up during the night?

Yes
No

Do you feel rested in the morning?

Yes
No

Do you dream often?

Yes
No

Do you take naps during the day?

Yes
No

What time do you go to bed?

What time do you wake up?

Head, Chest, and Breathing:

Please list any conditions that was not listed above

Skin/Sweat

Please list any other skin conditions:

Temperature:

Do you feel more towards cold or hot?

Please list any other conditions regarding your body temperature that was not listed above:

Emotions:

How would you describe your outlook on life lately?

Is there any emotions that is more difficult for you to feel?

Please describe any pain or tension that you have in your body, if there are any:

Vision

Do you experience any of the followings?

Blurred vision
Poor night vision
Dry eyes

Please list any other conditions related to your visions:

Hearing

Do you experience any of the followings?

Ear ringing
Ear aches
Popping

Please list any other conditions related to your hearings:

Taste:

Do you get weird tastes in your mouth?

Bitter
Metalllic
Sweet
Sour

Numbers

For Men

Other:

Is there anything else that you feel is important that hasn not been addressed on this form?