Practitioner Club Member Application Form

Age

Gender

Describe your symptoms, including frequency and duration

When did they start?

Is there anything that makes them better or worse?

Is there a family history of these symptoms?

How many hours do you sleep at night? What is the quality of your sleep out of 10?

What are your general stress levels out of 10?

Do you smoke? If so, how many a day?

How many standard drinks to you consume per week?

How many times a week do you exercise? What sort of exercise do you do?

Please list any allergies you have:

Are you pregnant?

Are you breastfeeding?

Medical Conditions: Do you have Arthritis?

Medical Conditions: Do you have Asthma?

Medical Conditions: Do you have Chemical sensitivities?

Medical Conditions: Do you have Coeliac disease?

Medical Conditions: Do you have Diabetes?

Medical Conditions: Do you have Epilepsy?

Medical Conditions: Do you have Glaucoma?

Medical Conditions: Do you have Heart condition?

Medical Conditions: Do you have High blood pressure?

Medical Conditions: Do you have Inflammatory Bowel Disease?

Medical Conditions: Do you have Lactose intolerance?

Medical Conditions: Do you have Thyroid?

Medical Conditions: Do you have other medical conditions? Please give details:

Medication History: What medications are you on?

Medication history: What supplements are you taking?

Referring practitioner's name:

Phone Number

Email Address

Address

Your message