Consultation Form

Name

Email Address

Address including Postcode

Telephone contact number/s

Date of birth

Height (in cm or feet / inches)

Weight (in kg or lbs / stones)

How will you be paying? How will you be paying? Self pay Insurance

Please describe your main complaint(s) in your own words

Condition(s) diagnosed by your GP/Consultant?

Do you know of any problems during your own birth? (Please describe)

Vaccinations: List any unusual vaccinations and reactions to vaccinations

Childhood: illnesses, surgery, accidents (with approx. age)

Adolescence: illnesses, surgery, accidents (with approx. age)

Adulthood: Illnesses, surgery, accidents (with approx. age)

Scars. Please write down location of all scars and operations

Major illnesses in your immediate family - such as diabetes, heart conditions, blood disorders, neurological problems, mental health problems, immune conditions, etc.

Medication: please write down all medication and nutritional supplements

Please indicate which of the following skin problem / diseases / symptoms you have NOW Please indicate which of the following skin problem / diseases / symptoms you have NOW Eczema Acne Skin rashes Dermatitis Psoriasis Fungal infections Furuncles Warts Dry/Oily skin None of the above

Other skins problem I have NOW

Please write down any skin problems that have affected you IN THE PAST

Please indicate if you have any of the following heart / cardio vascular problems NOW Please indicate if you have any of the following heart / cardio vascular problems NOW Fast pulse (more than 100 beats/min) Slow pulse (less than 60 beats/min) Palpatations Irregular heartbeat Feeling of pressure in the chest Chest pain Shortness of breath Dizziness Migraine Headache with nausea Cold hands/cold feet Raynaud's disease Flushed face Red face Anaemia High blood pressure Low blood pressure Cold sweats Dizziness when standing up quickly or a long time None of the above

Other heart / cardio vascular problem I have NOW

Please write down any heart problems you have had IN THE PAST

Please indicate if you have any of the following respiratory problems NOW Please indicate if you have any of the following respiratory problems NOW Asthma Bronchitis Emphysema Pneumonia Coughing Wheezing Lung abcesses Cystic fibrosis None of the above

Other respiratory problems I have now

Other respiratory problems I have had IN THE PAST

Please indicate if you have any of the following Gastrointestinal / digestive problems NOW Please indicate if you have any of the following Gastrointestinal / digestive problems NOW Constipation Diarrhoea Lack of appetite Always hungry Stomach pain Indigestion Heartburn Intestinal gas Belching Gastritis Ulcer Lack of stomach acid Haemorrhoids Pancreatitis Peritonitis Irritable bowel syndrome Polyps Gastrointestinal tumours Candidasis None of the above

Other gastrointestinal / digestive problems I have NOW

Other gastrointestinal / digestive problems I have had IN THE PAST

Please indicate which of the following hormonal imbalances you have NOW Please indicate which of the following hormonal imbalances you have NOW Underactive or overactive thyroid Diabetes Hypoglycaemia None of the above

Other hormonal imbalances I have NOW

Other hormonal imbalances I have had IN THE PAST

Please indicate if you have any male reproductive issues NOW Please indicate if you have any male reproductive issues NOW Impotence Premature ejaculation Erectile dysfunction Prostate gland problems Infertility Vasectomy None of the above

Other male reproductive problems I have NOW

Other male reproductive problems I have has IN THE PAST

Please indicate if you have any of the following female reproductive problems NOW Please indicate if you have any of the following female reproductive problems NOW Menstrual problems Painful periods Heavy/light/irregular periods Long (30+ days)/short (24 days) cycle Mid cycle bleeding Thrush Small/large/light/dark clots in menstruate Duration of menstruation:3/5/7 more days infertility or sub fertility (Early) manopausal symptoms Low libido Pregnancy/ies Terminations(s) None of the above

Other female reproductive problems I have NOW

Other female reproductive problems I have had IN THE PAST

Please indicate if you have any of the following autoimmune, viral or inflammatory conditions NOW Please indicate if you have any of the following autoimmune, viral or inflammatory conditions NOW Hashimoto's disease (thyroid) Rheumatism Systemic lupus Erythmatosus HIV/aids Hepatitis A/B/C/D/E Colitis Crohn's disease Alopecia (baldness) Allergy Food allergy Atopic dermatitis Neurodermatitis Cellulites Vulvitis Low immunity Rheumatic disease Rheumatic fever Arthritis Skin disease Myofascial syndrome Fibromyalgia Tendonitis Pericarditis Constant low fever Glomerulonephritis Plantar faciitis Scarlet fever Ear infections Streptococci/staphylococci infections Easily catch cold/sore throat Swollen glands None of the above

Other autoimmune problems I have NOW

Other autoimmune problems I have had IN THE PAST

Please indicate which of the following ear/nose/throat problems you have NOW Please indicate which of the following ear/nose/throat problems you have NOW Deafness Tinnitus (ringing in ear/s) Itchy ear Ear pain Frequent ear infections Sinus headaches Stuffy nose Yellow/green mucus Post-nasal drip Dry throat Itchy throat Constant sinus congestion Streptococcal throat infections Sore throat None of the above

Other ear/nose/throat problems I have NOW

Other ear/nose/throat problems I have had IN THE PAST

Please indicate if you have any of the following oral diseases NOW Please indicate if you have any of the following oral diseases NOW Bleeding gums Inflammation of the gums Dental abscess Mumps Stomatitis (inflamation of the mouth) TJM Toothaches without cavities None of the above

Other oral disease problems I have NOW

Other oral disease problems I have has IN THE PAST

Please indicate if you have any of these general problems NOW Please indicate if you have any of these general problems NOW Insomnia Psychosomatic weakness Exhaustion Emotional problems (angy/irritable/depressed/anxious) Difficulty to concentrate Easily get car sick/sea sick/air sick No appetite for breakfast Moody in the mornings Unusual sweating (palms, soles, chest, neck) Lack of enery None of the above

Other general problems I have NOW

Other general problems I have had IN THE PAST

Please indicate if you take any of the following medication/recreational drugs NOW Please indicate if you take any of the following medication/recreational drugs NOW Birth control pill Cigarettes Alcohol Cocaine Heroin Marijuana Anxiolitcs Antidepressants Sleeping tablets None of the above

Other medications/recreational drugs I take NOW

Other medications/recreational drugs I have taken IN THE PAST