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  • Client FormQuestionnaire

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:

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

Please tell me any additional information about your health

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:

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

 

Enter details on any supplements you are currently taking:

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

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

 

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.

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.

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



Alcohol Consumption - Please answer these questions if you drink alcohol







Recreational Drugs

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

Your Stress Levels and Reasons for Stress

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

Sleep Related Questions









Digestion Question








Bowels Motions Questions
















Urination Questions - How are your daily urination's?











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Woman Only Additional Questions

























Questions only for menopausal/non- menstruating women







Exercise Questions - Please answer




Dietary Questions – Please Answer

Please provide details of a typical day’s diet

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

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

Other Dietary Questions – Please Answer













Working Life

Appointment Day Preferences to meet with Angela






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captcha

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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