Customer Details:
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
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E-mail
example@example.com
Occupation
Date of Birth
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Month
-
Day
Year
Date
Reasons for your Treatment:
Other Treatments being received for same condition:
Current Medical Conditions?
Are you on any Medication? if so please write down your medication and supplements.
Previous Medical Conditions, Operations and Accidents
Covid 19
Have you tested positive to Covid
Have you received Vaccination Part 1
Have you received Vaccination Part 2
Other
Family History of Illness
Emotional Well Being: Have you ever experienced?
No
Yes
If Yes, was this diagnosed by Dr?
Anxiety
Depression
Stress
How do your rate your:
Not good
Could be better
OK
Good
Very Good
Energy Levels
Sleep
Fluid Intake
Digestive Health:
Yes
No
Could be better
Occassionally
Regularly
Regular Movements
Diahorrea
Constipation
IBS
About your periods?
Yes
No
Do you have regular period cycles
Are your period heavy
Are your period painful
Are you on the pill
Do you have a coil fitted
Are to peri menopausal/Menopausal
I don't have periods
Menstrual Cycle: What date did you start you last period?
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Month
-
Day
Year
Date
Is there anything else you would like to share with me about your monthly cycle?
How did you hear about us?
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Personal Recommendation
Website
Google
Local Magazine
Other (Please specify...)
Other
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