Health Consultation

HEALTH CONSULTATION FORM

Name
Name
First
Last
Address
Address
Town
County
Postcode
Doctors Address
Doctors Address
Town
County
Postcode
May we speak to your doctor if needed?

Symptoms Checklist

To enable me to gain a complete view of your health, please tick if you have any of the following symptoms.      

General
Ear, Nose, Throat
Skin
Respiratory
Cardiovascular
Musculoskeletal
Genitourinary
Gastrointestinal
Women Only

Diagnosed Diseases

If you have ever been diagnosed with any of the following diseases, please tick.
Diagnosed Diseases

Medical Procedures

Please answer Yes / No and give brief details including when for all of the following.
Have you had Major Surgery
Have you had Dental Surgery
Have you had Broken Bones
Have you had Root Canals / Mercury Fillings
Prescription Drugs (if yes please use the more information box to indicate frequency)
Please give results of any investigations, such as X-rays, mammograms, tests in the last 5 years.
Describe any allergies or food reactions that you experience.
Please note here major diseases or causes of death for parents, grandparents or siblings.

Lifestyle and Habits

Do you drink Tea or Coffee or both?
Are you Vegetarian?
Are you Vegan?
Please list any food supplements or herbs that you take on a regular basis
Give some indication of meals. Example of breakfast lunch and dinner for one day.

Mental and Emotional

Please tick which resonates. This is helpful when working with essential oil blends that can work into the brain's Limbic System and support the override of negative thought programs and self-talk that can alter our biology.
Negative Emotions
Positive Emotions

*These are organic essential oil blends from Epigenetics International
- they support the Limbic System, a complex set of brain structures involved in emotions, memory and arousal. It includes the amygdala, hippocampus, hypothalamus, and other interconnected regions, which regulate responses and form memories.
We can muscle test the appropriate essential oil blend for you, or one will be energetically matched to you in your Bio-energetic test on the Qest 4.

Please note here anything else that you think is important that has not been covered elsewhere. (this is OPTIONAL information)
PERSONAL HISTORY: Please feel open to giving as much detail as possible, for example. Birth / Conception, Childhood, Adolescence, Later life, Relationships with parents, Partner relationships, Relaxation, Spiritual Practice (OPTIONAL)

TERMS OF CONSULTATION:

Recommendations made by your practitioner are designed to improve your level of health and well-being, contribute to achieving your health goals, and to enable you to enjoy increased quality of life on a physical and mental level and emotional level. 

Please take note of the following:

  • you are responsible for contacting your GP or specialist about any health concerns you may have.
  • you are recommended to advise your GP about any treatment protocol you are following.
  • it is important to tell you practitioner about any medical diagnosis, prescription medication, food or herbal supplements that you are taking as it may affect the practitioner recommendations.
  • please report any concerns about your programme to your practitioner for discussion at your follow up consultation.
  • please take note of the time frame recommended for each part of the treatment plan and continue only as long as prescribed or check with your practitioner before continuing.  
  • Do not stop any medications from your doctor without his consent and check with doctor before embarking on any herbal or nutritional supplement that may affect current medication. 
PLEASE NOTE: If you would like a copy of your form please press Print BEFORE you submit your form.
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