PATIENT FORMS
Home
About
Terms & Conditions
Privacy Policy
Work with me
Book with Sari Young
Fundamentals Challenge
Endometriosis Fundamentals Challenge
Rebalance | Nutritional Balancing Program
Testimonials
FAQ
Free Resources
Contact
Challenge Log In
Patient Forms
Nutritional Balancing
Natural Living
Healthy Diet
General Health
Food as Medicine
Exercise
Detoxification
Cooking and Recipes
Children's Health
Patient Intake Form
This should take you approximately 10-15 minutes to complete. Please answer thoroughly and honestly and give the questions due consideration.
Your Name
(required)
Postal address
(required)
Email
(valid email required)
Date of birth
(required)
Age
(required)
Phone number
(required)
Religion
Blood type
(required)
Occupation
(required)
Number of children
(required)
What is your height in cm?
(required)
What is your weight in kg?
(required)
1. How did you hear about Sari's Natural Medicine?
Word of mouth
Sari's Natural Medicine website
Google
Newspaper
Flyer
Dr. L Wilson's website
Other
2. Please list your top three priorities in life:
(required)
3. List three health goals/ reasons why you came here today in order of priority.
(required)
4. How long do you think it might take you to achieve these health goals?
(required)
5. How motivated and committed are you to improving your health? Please select a number from 1 (not committed) and 10 (very committed).
1
2
3
4
5
6
7
8
9
10
6. What has helped motivate and inspire you to make significant life changes in the past and/ or what could help motivate and inspire you to make changes now? Please comment on how/ why these motivate you.
7. What, if any, limitations do you have in achieving your health goals?
Eg: time, money, lack of support, energy etc.
(required)
8. List any existing health conditions or concerns:
(required)
9. List any natural supplements, herbs and remedies you are currently taking:
(required)
10. List any medications you are currently taking:
(required)
11. List any recent medical tests you have had such as bloods tests. Please forward me a copy prior to your consultation.
(required)
12. Which, if any, natural practitioners are you currently seeing?
(required)
13. Please list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis.
(required)
14. Please rate the following on a scale of 1 (poor) and 5 (excellent).
General health and wellbeing
1
2
3
4
5
Why have you selected this rating?
Overall quality of your diet
1
2
3
4
5
Why have you selected this rating?
Sense of calm and relaxation
1
2
3
4
5
Why have you selected this rating?
Quality and quantity of sleep
1
2
3
4
5
Why have you selected this rating?
How many hours of sleep do you get per day?
(required)
Exercise and general activity levels
1
2
3
4
5
Why have you selected this rating?
How often and what kind of exercise do you do?
(required)
15. To improve your health and wellbeing you may be asked to make some changes to your diet and /or lifestyle. If requested to do so, how willing would you be to do the following? Please rate on a scale of 1 (not willing at all), to 5 (extremely willing).
Significantly modify your diet:
1
2
3
4
5
Engage in regular exercise/ activity:
1
2
3
4
5
Practice relaxation techniques on a regular basis:
1
2
3
4
5
Modify your sleep habits:
1
2
3
4
5
Have consultations to assess your progress:
1
2
3
4
5
I understand that Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease.
Signed:
(required)
Dated:
(required)
Thank you. I look forward to working together with you to help you reach your health potential.
Subscribe to my newsletter for healthy tips, articles and recipes and a free copy of my Virus Recovery Blueprint.
Sign Up
{"email":"Email address invalid","url":"Website address invalid","required":"Required field missing"}
Previous
Next
>
