If you would like to work with me please complete the following form which will give a good background from which to work – once you submit the form I will get back to you.

Please note:  This is in not an individual diagnosis of your health or prescriptive in any way.

 

online consultation

Name:
Address:

Telephone

Home:
-
Work:
-
Mobile:
-

E-mail:
Date of birth:
 /  / 

Height:
Weight:
Reason for Consultation:
Expectation:
Alcohol(Units per week):
Tobacco ( per day):
Caffiene (per day):

FAMILY HISTORY

Your family history:

PERSONAL HISTORY

Your personal history::
Operations:
Accidents:
Pre-menstrual Symptoms:
Treatment from a medical or alternative practitioner in last 2 years?. If yes please give details:
Medication/natural remedies?Please give details:

GENERAL HEALTH

Your general health:

MEMORY AND CONCENTRATION

Your memory and concentration:

NATURE

Your general nature:

CHARACTER

Your character:

SLEEP

Your sleep:

INFECTIONS

Infections:

HEAD

Head issues:

RESPIRATORY

Your respiratory system:

URINARY TRACT

Urinary tract issues:

DIGESTIVE SYSTEM

Your digestive system:

Stools:

- Frequency:
- Consistency:
- Colour:
- Odour:

CARDIOVASCULAR SYSTEM

Your cardiovascular system:

OSTEOARTICULAR SYSTEM

Your osteoarticular system:

SKIN, HAIR AND NAILS

Your skin,hair and nails:

ENDOCRINE SYSTEM

Your Pancreas:

ADRENAL GLANDS

Your adrenal glands:

HYPERTHYROIDISM

Hyperthyroidism:

HYPOTHYROIDISM

Hypothyroidism:

PARATHYROID DISTURBANCES

Parathyroid:

GENITALS

Genital Issues:
Pregnancies:
Miscarriages:

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