Initial Consultation Questionnaires

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.
Please "sign" and date the box below by typing your name and date that you are completing these forms.
Health Questionnaire

Please complete the following questionnaires prior to your consultation. All information will be treated with strictest confidence.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact - name and number
Date of Birth

DayMonthYear
Email
example@example.com
Mobile Number
Please enter a valid phone number.
Height
Current Weight
How much weight would you like to lose?

Do you suffer from any of the following conditions?

	Yes	No
Heart Disease
Raised Blood Pressure
Low Blood Pressure
Raised Cholesterol Levels
Type 1 Diabetes
Gastrointestinal Problems
Food Allergies or Intolerances
Chest Pain/Dizziness whilst exercising
Any other medical condition not listed

If you have answered yes to any of the above questions, or suffer from any other illness not listed, please provide further information below. You may be required to speak to your GP before you can begin with the SMASH programmes.

	Yes	No
Are you currently pregnant?
Are you currently breast feeding?
Are you currently taking any medication?
Have you ever taken antibiotics?
Do you take painkillers
Have you had the Co-vid Vaccination

If you answered yes to any of the above questions, please provide further information below.

Do any of your close family members suffer from, or have suffered from any of the conditions below?

	Yes	No
Heart Disease
High Blood Pressure
Type 2 Diabetes
Thyroid Issues
Cancer

If you answered yes to any of the above questions, please provide further information below.
Do you currently take any health supplements? If yes, please give details, stating brand, quantity and reason for taking.

	0	1	2	3	4
Nausea or Vomiting
Diarrhoea
Constipation
Bloated Feelings
Burping or Passing Wind
Stomach Pain
Cramps
Heart Burn

	0	1	2	3	4
Itchy Ears
Earaches or Infections
Drainage from the Ear
Ringing Ears
Hearing Loss

	0	1	2	3	4
Mood Swings
Anxiety
Fear or Nervousness
Anger/Irritability/Agressiveness
Depression

	0	1	2	3	4
Acne
Hives/Rashes
Hair Loss
Flushing/Hot Flushes
Excessive Sweating

	0	1	2	3	4
Fatigue
Sluggishness
Lethargy
Hyperactivity
Restlessness

Informed Consent, Medical Waiver and Release of Liability

Health Questionnaire

Lifestyle Questionnaire

Daily Habits Questionnaire

Toxicity Questionnaire

	0	1	2	3	4
Watery or Itchy Eyes
Swollen/Red/Sticky Eyelids
Bags/Dark Circles under the Eyes
Blurred/Tunnel Vision

	0	1	2	3	4
Poor Memory
Confusion
Poor Concentration
Difficulty in making Decisions
Stuttering/Stammering
Slurred Speech
Learning Difficulties

	0	1	2	3	4
Aches and Pains in the Joints
Arthritis
Stiffness/Limited Movement
Aches and Pains in the Muscles
Feeling of Weakness/Tiredness

	0	1	2	3	4
Chest Congestion
Asthma
Bronchitis
Shortness of Breath
Difficulty Breathing
Chest Infections

	0	1	2	3	4
Stuffy Nose
Sinus Problems
Hay Fever
Excess Mucus Formation
Sneezing Attacks

	0	1	2	3	4
Chronic Coughing
Gagging or Clearing Throat
SoreThroat/Hoarseness/Loss of Voice
Swollen Tongue/Gums/Lips
Mouth Ulcers

	0	1	2	3	4
Binge Eating
Binge Drinking
Craving Certain Foods
Excessive Weight
Compulsive Eating
Underweight

	0	1	2	3	4
Frequent Illnesses
Frequent or Urgent Urination
Genital Itch
Genital Discharge

	0	1	2	3	4
Headaches
Migraines
Dizziness
Insomnia