Pre Video Consultation Form Home Pre Video Consultation Form Pre-Video Consultation Form Name * First Last * Last Date of Birth * Age * Appointment Date * Email * Phone * Address (inc Postcode please) * Sex * Female Male Marital Status Children (inc Ages and Sex please) Occupation * Height Weight Waste Circumference GP Practise Name * GP Practise Address * Additional Information * I have emailed the requested info to enquiries@naturopath.clinic I’ve completed all these details in the form below I’ve not got around to this yet You will have seen in your booking email that I have asked you to provide additional info at your appointment. This includes; a food diary, medication and supplement lists Agreement * I have read and agree with the Terms of Engagement Form Link to form: https://www.naturopath.clinic/wp-content/uploads/2022/09/Terms-of-Engagement.pdf Signed hard copy available on request Confirmation * I have disclosed all relevant and requested information to the best of my knowledge and belief The Remainder Of This Form Is Optional The Symptom(s) you are most concerned about and want help with at this time. Any Current Prescription Medication ? Any Historical Prescription Medication ? Any Current Regular or Occasional Over The Counter (OTC) Medication ? Any Historical OTC Medication ? Any Current Regular Supplements ? Please List Any Medical Diagnoses Please tell me how your stool best fits the Bristol Scale 1234567 Look here: https://www.webmd.com/digestive-disorders/poop-chart-bristol-stool-scale How often do you pass a stool Do you experience any of these symptoms? Please give details if ‘yes’ to any Do you have any allergies? Yes No This is vitally important! Please give more details of your allergies Include the severity of any symptoms Please provide a 3 day food diary. Is there anything else you would like to add? We can cover most of it during our consultation Confirmation (Additional Info) I have disclosed all relevant and requested information to the best of my knowledge and belief Only required if you have completed the second half of this form – beyond the part that said “the remainder is optional” If you are human, leave this field blank. Submit
