Name* (required)
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Date of Birth* (required)
Gender* (required) Male Female Other
Address* (required)
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Country (If Other)
Your Email* (required)
Contact Number* (required)
Emergency Contact* (required)
Relationship with Emergency Contact* (required)
Phone Number* (required)
Medical Doctor
Phone Number
Address
How did you hear about us?* (required)
Health Goals/Concerns: What main health goals/concerns brought you to the clinic today?* (required)
For how long have you had it?* (required)
Can you trace the origin of your illness? (i.e. shock, worry, diet, over exertion, accident)
Previous practitioners consulted for this condition: MD/ ND/ Other* (required)
Please explain your diagnosis, therapy and results where applicable:* (required)
What types of therapy have you tried for this problem?* (required)
Diet modification Vitamin/mineral supplements Herbs Homeopathy Chiropractor Acupuncture Conventional drugs Osteopathy Other* (required)
What makes it better?* (required)
What makes it worse?* (required)
Please list any other health concerns or goals in order of importance* (required)
Occupation* (required)
Do you work in Shifts? Yes No
Do you enjoy your work? Yes No Sometimes
Hours/day you spend
Work Duration* (required)
Watching TV* (required)
Driving* (required)
In front of computer/screen* (required)
On a scale of 1 to 10, 1 being the lowest and 10 being the highest, what is the level of stress you are presently experiencing in your life?* (required)
Please list the major causes of stress for you (work, finances, relationship, health, etc.)* (required)
Have you experienced any major trauma, loss, or life changing significant events?* (required)
How would you describe your general state of health: Excellent / Good / Fair / Poor?* (required)
Any history of Hospitalization /Surgery/Injury?* (required) Yes No
Any Allergies and/or food sensitivities?* (required) Yes No
if yes, kindly share the Allergies and/or food sensitivities.
Current medications/supplements: Please list ALL medications or supplements you take on a regular basis: Medication/Supplement Dose (if known) Length of Use Prescribing Practitioner Are You Taking Presently?* (required)
Date of last complete physical exam* (required)
Have you taken antibiotics within the last 5 years? Yes No
If yes, how many times?
Were you frequently given antibiotics as a child?* (required) Yes No
if yes, how often?
Have you been vaccinated? If so, what vaccines have you received?
Do you have any allergies?
Diet and Health Habits:
General energy level out of 10 (1=lowest, 10=highest)* (required)
What time of day is it highest?* (required)
What time of day is it lowest?* (required)
Are you on a special diet?* (required) Yes No
if yes, please explain
Do you crave?* (required) Sugur Chocolate Salt Protein Fats Sour Other
If other, please specify foods
Do you feel thirsty?* (required) Yes No
How many glasses of water do you drink on an average day?
What temperature of beverages do you prefer?* (required) Cold Room Temprature Hot
How is your digestion?* (required)
Do you experience?* (required) Bloating Gas Diarrhea Constipation
Please check which of the following substances you are currently using? (If Applicable)
Please check which of the following substances you are currently using? (If Applicable)* (required) Alcohol Laxative/Purgatives Chewing or smoking Tobacco Pain Killers Recreational Drugs Coffee Exercise
if yes, how much?
Alcohol
Laxative/Purgatives
Chewing or smoking Tobacco
Pain Killers
Recreational Drugs
Coffee
Exercise
How many hours of sleep do you get each night?* (required)
Do you wake up feeling rested?* (required) Yes No
Do you wake up in the night?* (required) Yes No
Do you take Nap?* (required) Yes No
How long does it take to fall back asleep?* (required)
Have you ever been diagnosed with any of the following?* (required)
Any relevant family history of medical disease? Explain.* (required)
Please list any other illnesses of your relatives, such as: parents, siblings, grandparents, aunts and uncles* (required)
Is there anything else that you feel is important that hasn’t been addressed on this form?* (required)
I consent to Natural Homeopathic Solutions Inc. collecting the health and personal information in this form and using it to prepare for my consultation. I understand it is sent by email and stored securely for the clinic's records, and that this may involve a service that processes data outside Canada.
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