German New Medicine Screening Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Age
*
Gender
Left or Right Handed
Medical History
Chief complaints, treatments and dates of onset
Other major conditions in the past
Do you have allergies? If so, what kind and what are the symptoms?
Are you taking medications? If so, what type?
Hormone Status
Prepuberty
Between Puberty and Middle Age
Perimeno/Andropause
Meno/Andropause
Are you taking hormones or birth control pills?
Yes
No
Have you had surgery or medication that affects hormones?
Yes
No
Women: What age was your period onset and length of your cycles?
Please tick any that apply
Temperature (cold feet, night sweats, chills etc)
Sleeping issues (insomnia, trouble falling alseep)
Appetite change (eating more or less)
Weight change
Frequent urination
Irregular bowel movements
Current Life Situation
Family: partners, children, pets
Work: type, recent changes, conflicts
Current emotional/mental state and stressors
Current physical state
How strong are you?
Weak
Medium/normal
Strong
What is your energy level?
No energy at all
Little amount of energy
Regular amount of energy
Excess amount of energy
Do you have a healthy/active lifestyle?
Yes
No
Do you have a healthy diet?
Yes
No
Do you have time to rest/relax?
Yes
No
Support System
Do you have someone for a support system?
Yes
No
Are your other practitioners supportive of alternative therapies?
Yes
No
Are you comfortable proceeding with a therapy in which they don't agree?
Yes
No
Knowledge of German New Medicine
How did you find out about GNM?
How much have you studied it?
Are you willing to take webinars/ask questions to increase your understanding about your symptoms and what the healing path entails in GNM?
Yes
No
Do you agree to give consent to collaborate with other practitioners?
*
Yes
No
I understand:
The clinic does not guarantee results, as with all forms of medicine, German New Medicine has its limitations.
The German New Medicine Educator will explain the exact nature of my treatment and will answer any questions that I may have.
I am free to withdraw my consent and discontinue treatment at any time.
German New Medicine can be followed in conjunction with other forms of therapy. I need not choose one method of treatment over the other.
Signature
*
Date
*
Thank you for answering these questions honestly and to the best of your ability. I look forward to speaking with you further about the possibility of applying German New Medicine to your healing.
Warm regards, Dr. Katherine Willow N.D.
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