Surname & First Names
Sex Female or Male
Age in Years
Date of Birth
A Contact Land Line Phone Number
Your Doctors Name
Complaint Details (1000 chars left)
Health Details (1000 chars left)
When listing your medications, please include the following details for each medication:
Medication Details (1000 chars left)
When listing your supplements, please include the following details for each supplement:
Supplement Details (1000 chars left)
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)
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
How long have you smoked?
How Many Cigarettes per day?
Between what ages did you smoke?
How many cigarettes per day did you smoke?
How often do you drink alcohol?
Once or Twice a Week
Three or four times a week
Never Drink Alcohol
When you do drink, what (wine, beer etc) & how much do you consume?
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?
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?
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)
How is your sleep? Select options that describe your sleep patterns.
Hard to get to sleep
Wake up often
Get up during the night
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)
Which of the following best describes your digestive health/symptoms:
Burning/pain in stomach
How often do you pass stools (poo)?
If you do skip days, how many days typically is it before having a bowel motion?
Other Stool Issues:
Lots of mucus
Lots of gas
Describe any pain:
Any other Stool related symptoms:
How often do you urinate?
Every 2 to 3 hours
Sense of urgency
Too small amount
Too large amount
Do you need to get up out of bed & urinate several times over night?
Describe any other urination Problems?
Are you pregnant?
Are you breastfeeding?
Are your monthly periods regular (around 28 days cycles)?
Number of days of menstrual flow?
Symptoms experience associated with your period:
Bright red blood
Dark clotted blood
Any other menstrual symptoms or changes? (500 chars left)
Do you have children?
How old are your children?
Have your periods stopped?
Have your periods changed or become irregular (please detail)? (500 chars left)
Have you had a Hysterectomy?
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)
Do you exercise?
Yes I 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?
Please provide details of a typical day’s diet
Main meals - Enter the number of meals you consume per week out of the following:
Red meat meals:
Beverages – Enter the number of drinks you consume per day out of the following:
Herb tea (please name type of teas):
Choice of milk type (if any):
Other Dietary Questions – Please Answer
What type of Spread do you use?
I do not use spreed
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
Skip meals often
Eat a lot of convenience food (boxed/packet foods, etc)
Eat mostly homemade meals
A lot of raw food
In transition of eating better
Do you work?
I work full-time
I work part-time
I do not work
I’m currently not working
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?
Please select your preferred day
Any day that is available
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Angela Frieswyk, BSc, Dipl Herb Med, NZAMH