Female Client First Time Evaluation Form

Female Client First Time Evaluation Form

Angela Frieswyk, Medical Herbalist & Holistic Nutritionist, Tauranga
Please Note the following:
1. Prior to your very first consultation, could you please fill-in this form and send it to me by clicking on the Submit Button at the bottom of the form.
2. Allow a good 10-15 minutes to complete the form.
3. Some questions on this form are marked as "required" by showing a red asterix to the right of the question heading. You will get an Error Warning in a red box at the top of the form if you have not answered all the required questions. Please enter your answers for each of the required question, then press the blue Next Button.
4. At any time while completing this form, you can step backwards through the various sections by clicking on the "Back" button at the bottom of each section of the form. You can make changes on what you have already entered. Likewise, you can move forward through the form by clicking on the blue "Next" button.
5. All information entered by you is kept strictly confidential. The detail is used to allow me time to review your health basics and focus on priorities during your consultation.
6. 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). As an alternative, you can electronically attach these reports at the end of this form.

Your Personal Details:
Name*

First NameLast Name
Age in years:*
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

City/TownState / Province

Postal Code
A Contact Land Line Phone Number

Area CodePhone Number
Mobile Phone Number
Please enter a valid phone number.
Your Email Address*

Confirmation EmailPlease confirm your email address again. This is a required check to confirm that you have entered the same email address.
Your Doctors Name and GP Practice:
Referred by

Your Health

Current complaints/symptoms, Medications, Supplements, Surgery & Dental Work
Please list current complaints/symptoms and rate severity: (1 to 10 scale, 10 being the most severe)
Please tell me any additional information about your health
Your Medications/Supplements

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. Medication name
2. Dose
3. How long you have used it
4. Why it was prescribed (if known).
Enter medications details
Enter supplement details
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.
List any surgery procedures details
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
Dental details

Cigarette Smoking, Alcohol Consumption & Recreational Drugs

Please answer these questions if you are or have been a cigarette smoker.
Current Smoker*

NoYes
Current Smoker - How long have you smoked?
Current Smoker - How Many Cigarettes per day?
Ex Smoker

NoYes
Ex Smoker - How long had you smoked?
Ex Smoker - How Many Cigarettes per day?
Alcohol Consumption

Please answer these questions if you drink alcohol
How often do you drink alcohol?*

Most DaysOnce or Twice a WeekThree or four times a weekSpecial OccasionsNever Drink Alcohol
When you do drink, what (wine, beer etc) & how much do you consume?
Recreational Drugs

Please only answer the following questions if you use any Recreational Drugs. Any information provided will be kept strictly confidential.
What Recreational Drugs do you use? Please provide information on how long you have used the drug and how much you regularly consume?

Sleep Questions and Stress Levels
Sleep Related Questions
How is your sleep? Select options that describe your sleep patterns.*

RestfulRestless / Wake up oftenHard to get to sleepBad dreams
Other Sleep Symptoms?
What time do you usually go to sleep?*

Hour Minutes

AM/PM Option
What time do you usually awake?*

Hour Minutes

AM/PM Option
Is your bedroom Dark or Light?*

DarkQuite Light
Your Stress Levels and Reasons for Stress
Please rate your current stress level (on a scale of 1 to 10, 10 being the highest).*
What if any is the main reason(s) for your stress?

Family Illnesses

Please provide details on any illnesses in the immediate family.
Mother Illnesses
Father Illnesses
Siblings Illnesses
Your Children Illnesses

Appointment Day Preferences to meet with Angela
Please select your preferred day*

Any day that is available.Monday.TuesdayWednesday.Thursday.Friday.
Time of Day for Appointment?*

Any time.A morning appointment.An afternoon appointment.
Attach Medical Reports and Images?

Please attach any Recent/relevant blood tests or medical reports you may have that are relevant to your appointment with Angela. You can also use the file uploads facility to upload images/photos of a condition you may have e.g. skin infection. File types allowed: pdf, doc, docx, xls, xlsx, rtf, zip, jpg, jpeg, png. Maximum upload 20MB.
File Uploads

Cancelof
Anti Spam - Please enter the code or press the refresh button for another code to enter.*
Please Note:

You can step back through the form if you wish to check on any details you have entered by using the "Back" Button at the end of each section, likewise you can press the "Next" Button to step forward through each section.

If you have entered all the required information correctly including the anti-spam check, you can press the green Submit Button.

You will know if everything is in order and that the form you have just completed has been sent to Angela if you get a Thank You message from her.
Should be Empty:

Your Personal Details: