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Health Guest Registration Form

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I wish to have specific help dealing with: (example: High BP, Arthritis, Smoking, Diabetes, Depression, Sinusitis, Prostate disorders, Overweight, Stress, Allergies, Asthma, Heart disease, others)
Are you following any special diet, or are you allergic to any foods? Please explain below.

Medical History

Providing the following information will allow a better understanding of your condition, and enable us to help you more when you arrive. The information you give will remain confidential and will be used for the purposes of constructing your personalized treatment plan. 

Give a brief medical history - names and dates of past ailments, operations, past complaints etc. 

When did you last consult a physician ?
What are you currently being treated for? 
What medicine, pills or drugs are you taking now? How many of each and how often?             (example: Tylenol 2 capsules, 3 times daily with each meal) 
What mineral and/or vitamin supplements are you taking? How many of each and how often? 
Do you, or have you ever use other non-prescription drugs?  If so, what types? 

Do you suffer from any of the following: Indigestion, Gas, Bloating, Diarrhea, Constipation (please write it below)

How often do you have bowel evacuations?

Describe the colour and texture of usual stool: 

What colour is you urine usually? 

Do you use tobacco ? If so for how long now? 

If not, have you used tobacco before and for how long?

Do you  drink alcohol ? If so for how long now?

If not, have you drunk alcohol before and for how long?

Do you consume caffeine in any form? If so for how long now?

If not, have you  consumed caffeine before and for how long?

Do you now have or have you had any of the following? Please write below

  • Acne  

  • Alcoholism  

  • Allergies

  • Anemia

  • Angina  

  • Appendicitis  

  • Arthritis  

  • Asthma  

  • Atherosclerosis  

  • Bad Breath (Chronic)  

  • Bell's Palsy  

  • Bronchitis  

  • Cancer  

  • Candida  

  • Cataracts  

  • Celiac Disease  

  • Chemical Poisoning  

  • Chills or cold skin

  • Colitis  

  • Conjunctivitis  

  • Crohn's

  • Disease

  • Depression  

  • Diabetes  

  • Digestive Disorders  

  • Diverticulitis  

  • Eczema

  •  Emphysema  

  • Endometriosis  

  • Fatigue (Chronic)  

  • Fibrocystitis  

  • Gallstones

  • High Blood Pressure  

  • Insomnia  

  • I.B.Syndrome  

  • Lumbago

  • Gout  

  • Hay Fever  

  • Headaches  

  • Heart

  • Disease/Attack  

  • Hemorrhoids  

  • Hepatitis

  • Hernia

  • Lupus  

  • Meniere's Disease  

  • Mental Disorders

  • Migraine  

  • Nervous Disorders  

  • Osteoporosis  

  • Pancreatitis  

  • Parkinson's Disease  

  • Peptic Ulcer  

  • Poliomyelitis  

  • Prostatitis  

  • Psoriasis  

  • Raynaud's Phenomenon

  • Respiratory Problems  

  • Restless Leg Syndrome

  • Rheumatic Fever

  • Rheumatoid Arthritis  

  • Sexual Disorders  

  • Shingles

  • Sinusitis  

  • Skin Problems  

  • Thrush  

  • Tinnitus  

  • Tonsillitis  

  • Tuberculosis  

  • Tumours  

  • Ulcers  

  • Vaginitis  

  • Varicose Veins  

  • Venereal Disease  

  • Venous Thrombosis