Name

Email

Address

Phone Number

Main Concerns and List the complaints and what treatments are you seeking for (Naturopathy, Kinesiology, Remedial Therapies, Beauty Therapies etc..)

History of Health and Family History (Grandparents, mother, father and siblings if you know of)

List the Medications and Supplements that you are presently taking and in the past

Are you seeing other practitioner/s now or in the past? List any medical diagnosis and types of treatments

List Blood type and Blood profile, disease, if you know of any (eg: blood clot: parents, grandparents etc.. Anemia, thalassemia, hemochromatososis, sickel cell etc..)

Sex: Male or Female Sexual Activity: Straight, Gay or Bisexual Partner, Single, Married or Divorce