CONSULTATION FORM NameFirstLast Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Phone Email Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Height Weight: Reason for Consultation: Expectation: Alcohol(Units per week): Tobacco ( per day): Caffeine (per day): FAMILY HISTORYAllergiesBP ProblemsArthritisStrokeCancerHeart DiseaseNeuropsychiatric DiseaseObesityGoutJoint DiseaseBlood Disease PERSONAL HISTORYMeaslesVaccinationsChicken PoxAllergiesColdsBronchitisScarlet FeverTonsilitisAsthmaGlandular FeverGerman MeaslesEczemaFluWhooping Cough Operations: Accidents: Pre-menstrual Symptoms: Treatment from a medical or alternative practitioner in last 2 years?. If yes please give details: Medication/natural remedies? Please give details: GENERAL HEALTHChronic tiredness, general lassitudeTiredness in the morningProgressive tiredness owing to lack of resistanceTiredness in the morning, reappearing in the afternoonIrregular tiredness, exhaustionTires after effortRefreshed by effort, tireless in the eveningHas always been like this URINARY TRACTFrequent or infrequent urinationCystitisBed-wettingIncontinence HEADHeadaches, migrainesAuditory disturbancesDizziness, drop in BP, feel faintDizziness, low BP, feeling faint SLEEPNeed for lot of sleepDuration of sleep reduced because of intense lifePoor sleep with anxiety, waking during the nightDifficulty getting to sleepPoor sleep with nightmaresDrowsiness CHARACTERCalm, thoughtful, self-controlledNervous, choleric, easily 'carried away', impatientNervous. anxious, emotionalApathetic. listless, general lack of interestAlternating moods MEMORY AND CONCENTRATIONSelective, recent memory disturbancesReduced in relation to tiredness Reduced with ageVery poor NATUREVery energeticModerately energeticLess energy than beforeLacking in energySlight pessimism, anxiety, emotional liabilityPessimism with depresssionMental state neither good nor badMental state fluctuatingOptimism INFECTIONSSusceptible to infectionsVery susceptible to infectionsAdenitisStaphyloccal infectionTBOthers RESPIRATORYENT infectionsHayfeverHayfever with infections complicationsAsthmaBronchitic AsthmaBronchitisSinusitisPleurisyBreathlessness Your digestive system:Irregular appetiteLack of appetiteFood intoleranceNauseaConstipationDiarrhoeaAlternating Constipation/DiarrhoeaSlow DigestionColicWind/Bloating/Flatulence/BurpingPeritonitisGastritis DuodenitisUlcerChronic EnterocolitisColitis/Rectocolitis/SigmoiditisStools: Frequency: Consistency: Colour: Odour: Your osteoarticular system:Fleeting painsChronic, progressive pain, deformitiesJoint disease; pain at start of day, every dayArthritis; pain all day during 'flare up'GoutOsteomyelitis Your skin,hair and nails:Non-infected eczemaInfected eczemaPruritis (itching), Urticaria (hives)Quincke's OedemaBrittle hair and nailsHair loss Your Pancreas:Undigested stoolsPutrid diarrhoeaWeight lossWeaknessExhaustionRavenous Appetite Your adrenal glands:Loss of strength and physical weaknessHypotensionDepressionVomitingDiarrhoeaDrowsiness Hypothyroidism:HypotensionSlow wittednessApathy'Chilly' feelingConstipation Parathyroid:Hyper reflexia (muscle twitching)Hyperexcitability (excessive mental and physical activity)Cardia Arrhythmias, TachycardiaMuscular contracturesSpasms Genital Issues:Frigidity, ImpotenceFrequent, heavy, painful menstruationInfrequent, light menstruationIrregular menstruationMenstruation absentMenopausal disturbancesSterility Pregnancies: Miscarriages:Thank you for filling in this form.To finish please now click the Submit button belowSubmitReset