Client First Time Evaluation Form for Angela Frieswyk's clients to complete

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Client First Time Evaluation Form

Please note the following:

Prior to your very first consultation, could you please fill-in the information requested contained within this form and send it to me by clicking on the Submit Button at the bottom of the form.
Questions with a red * to the right must be answered.
If you do not get the 'Thank You' message after clicking on the Submit Button to send the form to Angela, there will be items that you have missed when entering data into the form. A message will appear near the top of the form. Please review the form, make corrections/additions and then click on the Submit Button.
All information is kept strictly confidential. The detail is used to allow me time to review your health basics and focus on priorities during your consultation.
Drink adequate water before your consultation (good hydration required for QRA checks).
Try to avoid coffee/alcohol immediately before your consultation (effects conventional as well as alternative diagnostic techniques).
If you have any recent/relevant blood tests or medical reports, please bring these with you (request a copy from your doctor’s clinic or specialist).

Please Note

Angela will be unavailable for consultation from the 1st of January until the 17th of January 2020. If you would like to make a booking after this time please fill in the online form and Angela will make contact with you shortly. All repeat script requests should be directed to the Wild Herbs dispensary, 578 7211 ext 2.

Please Enter your Personal Details:

Surname & First Names *

Sex Female or Male Female
Male

Age in Years

Date of Birth

Address *

City/Town *

A Contact Land Line Phone Number

Mobile

email address

Your Doctors Name

Referred by

Please list your current complaints/symptoms and rate their severity (on a scale of 1 to 10, 10 being the most severe)

Complaint Details (1000 chars left)

Please tell me any additional information about your health

Health Details (1000 chars left)

Enter details on all your Medications, including birth control pills, pain medications, laxatives, etc.

When listing your medications, please include the following details for each medication:

The prescription medication name shown on your prescription label.
The dosage information, for example, 2 tablets of 10MG daily, half hour before breakfast.
The time period in years or months or weeks that you have been taking this medication.
The reason, if known, for you taking this medication.

Medication Details (1000 chars left)

Enter details on any supplements you are currently taking:

When listing your supplements, please include the following details for each supplement:

The supplement name shown on the label.
The dosage information, for example, 2 tablets of 10MG daily, half hour before breakfast.
The time period in years or months or weeks that you have been taking this supplement.
The reason, if known, for you taking this supplement.

Supplement Details (1000 chars left)

Surgery History

Please list any surgery procedures you have had and the time period in years or months or weeks since you had this surgery.

Surgery Details (1000 chars left)

Dental Work

If known, please provide details on the number of silver fillings, composite fillings, root canals or other dental work you currently have. Also note if you have current dental problems that need attending to.

Dental Work Information

Cigarette Smoking - Please answer these questions if you are or have been a cigarette smoker.

Current Smoker? Yes
No

How long have you smoked?

How Many Cigarettes per day?

Ex-smoker Yes No

Between what ages did you smoke?

How many cigarettes per day did you smoke?

Alcohol Consumption - Please answer these questions if you drink alcohol

How often do you drink alcohol? Every Day
Most Days
Once or Twice a Week
Three or four times a week
Special Occasions
Never Drink Alcohol

When you do drink, what (wine, beer etc) & how much do you consume?

Recreational Drugs

Please only answer the following questions if you use any Recreational Drugs. Any information provided will be kept strictly confidential.

What Recreational Drugs do you use?

Please provide information on how long you have used the drug and how much you regularly consume?

Your Stress Levels and Reasons for Stress

Please rate your current stress level (on a scale of 1 to 10, 10 being the highest stress):

What is the main reason(s) for your stress?

Family Illnesses - Please provide details on any illnesses in the immediate & extended family

Mother Illnesses (500 chars left)

Father Illnesses (500 chars left)

Siblings Illnesses (500 chars left)

Your children Illnesses (500 chars left)

Any notable illnesses in past/present extended family members? (500 chars left)

Sleep Related Questions

How is your sleep? Select options that describe your sleep patterns. Restful
Restless
Hard to get to sleep
Wake up often
Get up during the night
Bad dreams

Other Sleep Symptoms? (300 chars left)

What time do you usually go to sleep?

What time do you usually awake?

Is your bedroom Dark or Light (select from list) Dark
Quite light

Digestion Question

Which of the following best describes your digestive health/symptoms: Adequate
Poor
Acid reflux
Burp often
Burning/pain in stomach
Bloating
Other symptoms

Bowels Motions Questions

How often do you pass stools (poo)?

If you do skip days, how many days typically is it before having a bowel motion?

Stool Amount: Normal
Too little
Too large

Stool Consistency: Normal
Too hard
Very soft
Diarrhea

Stool Colour: Brown
Black
Yellowish
Other

Other Stool Issues: None
Lots of mucus
Lots of gas
Foul smell

Describe any pain:

Any other Stool related symptoms:

Urination Questions - How are your daily urination's?

How often do you urinate? Every 2 to 3 hours
Too frequently
Infrequently

Urination problems: None
Sense of urgency
Too small amount
Too large amount
Burning
Dribbling
Unusual smell

Do you need to get up out of bed & urinate several times over night? *

Describe any other urination Problems?

Woman Only Additional Questions

Are you pregnant? Not Applicable
Yes
No

Are you breastfeeding? Not Applicable
Yes
No

Are your monthly periods regular (around 28 days cycles)? Not Applicable
Yes
No

Number of days of menstrual flow?

Symptoms experience associated with your period: Not Applicable
None
Cramping
Bloating
Feeling weak
Mood swings
Cravings
Heavy bleeding
Back pain
Headaches
Bright red blood
Dark clotted blood

Any other menstrual symptoms or changes? (500 chars left)

Do you have children? Not Applicable
Yes
No

How old are your children?

Questions only for menopausal/non- menstruating women

Have your periods stopped? Not Applicable
Yes
No

Have your periods changed or become irregular (please detail)? (500 chars left)

Have you had a Hysterectomy? Not Applicable
Yes
No

If you have had a Hysterectomy, when did you have it and why?

Please detail any other symptoms of menopause you are experiencing: (500 chars left)

Exercise Questions - Please answer

Do you exercise? Yes I exercise
Incidental exercise
No exercise

If so, what kinds of exercise do you participate in?

How often do you exercise?

When you exercise, how much time do you spend exercising?

Dietary Questions – Please Answer

Please provide details of a typical day’s diet

Breakfast:

Morning snack:

Lunch:

Afternoon snack:

Evening snack:

Main meals - Enter the number of meals you consume per week out of the following:

Red meat meals:

Chicken meals:

Fish meals:

Egg meals:

Vegetarian:

Beverages – Enter the number of drinks you consume per day out of the following:

Coffee:

Tea:

Green tea:

Herb tea (please name type of teas):

Water:

Milk:

Choice of milk type (if any):

Other Dietary Questions – Please Answer

What type of Spread do you use?

How many vegetable serves per day do you consume (1 serve = ½ cup when raw)

Fruit - Choice and number of fruit per day

Tick boxes that best describes your diet preferences/habits (you can tick more than one if required): Mostly eat out (fast food)
Mostly eat out (but try to eat healthier items)
Eat whatever is available
Occasional binges
Skip meals often
Eat a lot of convenience food (boxed/packet foods, etc)
Eat mostly homemade meals
Vegetarian
Vegan
Mostly organic
A lot of raw food
In transition of eating better

Working Life

Do you work?

Employment/Self-employment History: What kind of work do you (or did you) do? (500 chars left)

If employed, how many hours do you work a week?

Appointment Day Preferences to meet with Angela

Please select your preferred day Any day that is available
Monday
Wednesday
Thursday
Friday
*

Anti Spam - Please enter the code or press the refresh button

If you have entered all the required information correctly you can press the Submit Button(to the right or the bottom of this form).

You will know if everything is in order if you get a Thank You message from Angela. If this message does not appear, it means that you have missed something or entered something incorrectly! That being the case, go to the top of this form and you will see an error message in red print, read the message, then go into the form to make the correction and attempt to send the form again by reentering the security code again, then click on the Submit button.

If for whatever reason you can not send this form to Angela, do not worry as you can make an appointment with Angela and give her this information at that time. The purpose of this form is to save time when you meet with Angela.

Thank You for completing the information and sending me your information. I will be in touch soon to arrange an appointment.

Angela Frieswyk, BSc, Dipl Herb Med, NZAMH

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