Consultation Form

Client's Name: *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tel No. & Mobile No.: *

(###)

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Birth Date *

MM

DD

YYYY

Any hereditary illness that you can think of such as:

Cancer

Diabetes

Stroke

Heart Disease

TB

Nervous Breakdown

Asthma

Hepatitis

YOUR HEALTH & CONSTITUTION: RESPIRATORY & CARDIOVASCULAR

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Sore Throat

Coughing Up Blood

Nasal Problems

Cough

Nose Bleed

Asthma or Wheezing

Pneumonia

Bronchitis

Shortness of Breath

High Blood Pressure

Irregular Heart Beat

Dizziness

Chest Pain or Pressure

Leg Cramps

Cold Hands/ Cold Feet

YOUR HEALTH & CONSTITUTION: GASTROINTESTINAL *

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Indigestion

Gall Stones

Abdominal Pain or Cramps

Diarrhea

Constipation

Blood in Stool

Heartburn

Excess Appetite

Increased Appretite

Excess Thirst

Nausea and Vomitting

Colitis

Diverticulitis

Belching or Burping

YOUR HEALTH & CONSTITUTION: SKIN

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Ulcerations

Rash or Dry Skin

Oedema

Dermatitis

Acne

Psoriasis

Eczema

YOUR HEALTH & CONSTITUTION: MUSCULOSKELETAL *

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Back Pain

Curvature of the Spine such as Scoliosis

Painful Joints

Break bones easily

Stiff Joints

Arthritis

Muscle Pain or Cramps

YOUR HEALTH & CONSTITUTION: GENITOURINARY *

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Frequent Urination

Painful Urination

Bloody Discharge

Venereal Disease

Pain in the Genital Area

Decrease Sex Drive

YOUR HEALTH & CONSTITUTION: Males Only

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Prostate Problems

Pain in the Testicles

YOUR HEALTH & CONSTITUTION: Females Only

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Pre-Menstrual Pain

Irregular Menstrual Pain

Irregular Menstrual Cycle

Swelling or Pain in the Breast

YOUR HEALTH & CONSTITUTION: MISCELLANEOUS *

Note: Please tick the box if you ever experience any of the following - sometimes or always.

Jaundice

Hepatitis

Memory Loss

Hearing Loss

Intolerance to weather change

Ringing in the Ears

Fever

Insomnia

Chills

Night Sweats

Kidney Stones

All the information that I've given is true. The treatment has been explained to me and I consent the treatment as explained. *

AGREE

NOT AGREE