Client Consultation Form

client consultation form

First Name

Last Name

Phone

Address

Gender

Date of Birth

What medications are you taking and what are they for?

Have you taken any steroids in the last year and if so, what for?

Have you taken a course of antibiotics in the last year and if so, what for?

Please detail all serious injuries, illnesses, infections and organ removal (tonsils, hysterectomy, etc) specifying what and when:

How many cups of tea/coffee or other caffeine drinks (eg Cola) do you consume per day? Please state how many of each:

Do you consider yourself to be overweight and if so how much?

How many times per week do you exercise for 20 minutes or more? What form does this exercise take?

Do you take any supplements (vitamins / herbs etc) and if so what (please feel free to state which brands you use)?

Please give a brief breakdown of your current diet (E.g. Breakfast, Lunch, Dinner, Snacks, Drinks)

How many mercury or other metal fillings do you have in your teeth?

How many cigarettes do you smoke per day?

How many units of alcohol do you drink per week?

How many times each day do you consume sugar?

How many glasses of water/fruit/herb teas/pure unsweetened fruit juice do you drink per day?

Please assess your personal stress level on a scale of 0 - 10 :

How many times per week do you have a bowel movement?

Please Include details of symptoms you are presenting