• Informed Consent, Medical Waiver and Release of Liability

    I understand that the purpose of working with SMASH Worldwide and Sandra Miskimmin is to help me gain a better understanding of my diet, its role on my weight management and information on naturopathic options for better health. 

    The role of Sandra is to develop an appropriate health-supportive/weight management programme for me, and to monitor my progress in achieving my goals.  A healthy lifestyle is of utmost importance in order to achieve this. 

    I understand that the purpose of these sessions is not to diagnose or treat disease and these sessions are not a substitute for appropriate medical treatment. 

    I understand that she will keep a record of our work together including screening forms and session notes. These will be stored securely and no information either verbal or written will be shared with a third party without my explicit consent.

    I agree to be honest in all of the information that I provide. Honesty is vital in order for me to get maximum results.

    I understand that working with Sandra will involve being weighed and taking body measurements - either in person or done remotely by yourself.

    I understand that photographs shall be taken to show me how much I have progressed during your programme. These shall not be shared without my permission.

    I understand that SMASH can not be held responsible for my actions when it comes to advice regarding weight loss and my weight loss is entirely my respsonsiblity.

     


    Medical Waiver and Release of Liability

     


    Sandra Miskimmin is not responsible for negligence, negligent use or health related consequences regarding the use naturopathic nutritionist advice given. Sandra Miskimmin cannot be held responsible for lack of education regarding the use naturopathic nutrition. 

     


    By signing below you accept the terms and conditions and agree not to hold Sandra Miskimmin responsible for any issues that may arise from the use of naturopathic nutrition and the advice of Sandra Miskimmin.

    By signing this agreement, you are confirming that all the information that you are giving is correct.

  • Health Questionnaire

    Please complete the following questionnaires prior to your consultation. All information will be treated with strictest confidence.
  • Date of Birth
     - -
    2 digit day, 2 digit month, 4 digit year
  • Format: 00000 000 000.
  • Do you suffer from any of the following conditions?
    Rows
  • Rows
  • Do any of your close family members suffer from, or have suffered from any of the conditions below?
    Rows

  • Lifestyle Questionnaire

    This will enable me to see your lifestyle and energy expenditure. This is important so we can ensure that you are eating the correct amount of food for your body long term.
  • How would you describe your level of activity at work?
  • What are your current health goals? Please tick as many as appropriate
  • Have you tried to achieve these goals in the past?
  • Do you have support from your family and friends on your health journey?

  • Daily Habits Questionnaire

    The answers to these questions will give me an insight into your daily habits. Please give as much detail as possible and be 100% honest. The more information I have the better I can help you.
  • When do you mainly eat during the day?
  • How often do you eat between meals?
  • What do you eat after your main meal of the day?
  • How often do you use sugar
  • How often do you eat chocolate and sweets?
  • How often do you eat cakes and pastries?
  • When preparing meals, in general, do you...
  • How many portions of fruit do you eat daily?
  • How many portions of vegetables do you eat on a daily basis?
  • At meal times, do you...
  • Which do you like best
  • How many snacks do you eat daily?
  • How much plain water do you drink daily?
  • How often do you drink alcohol?
  • On a monthly basis, how often do you eat ready meals?
  • On a monthly basis, how often do you eat takeaway meals?
  • On a monthly basis, how often would you go out for a "coffee"?
  • On a monthly basis, how often would you eat out in a restaurant or cafe?
  • On a monthly basis, how often would you have desserts/puddings?
  • How often do you exercise?
  • If you do exercise, what kind do you do?
  • How many hours do you have available to exercise on a weekly basis?
  • When do you prefer to exercise?
  • Do you suffer from stress?
  • How many hours sleep do you get each night?
  • How would you rate your quality of sleep?
  • Do you smoke?
  • How much time do you spend driving on a daily basis?
  • How much time do you spend sat down each day? Include time at a desk, watching TV, in front of a computer/ipad/phone etc
  • Do you use any of the following in your home?
  • Have you ever been on a foreign holiday?

  • Toxicity Questionnaire

    Answer the following questions using the following grading system - 0 = never suffer from, 1 = Sometimes suffer from the issue but the effect isn't too bad, 2 = Sometimes suffer from the issue and the effect is severe, 3 = Regularly suffer from the issue the effect isn't too bad, 4 = Regularly suffer from the issue and the effect is severe. (For example, if you suffer from a migraine once a month but it is manageable with medication your answer would be "1". If you suffer from migraines a couple of times a month and you end up in bed unable to function, you answer would be "4".
  • Digestive Tract
    Rows
  • Ears
    Rows
  • Emotions
    Rows
  • Skin
    Rows
  • Energy/Activity
    Rows
  • Eyes
    Rows
  • Head
    Rows
  • Mood
    Rows
  • Joints and Muscles
    Rows
  • Lungs
    Rows
  • Nose
    Rows
  • Mouth/Throat
    Rows
  • Weight
    Rows
  • Other
    Rows
  • Should be Empty: