Patient Profile 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)Email(valid email required)Date of birth(required)Age(required)Phone number(required)ReligionBlood type(required)Occupation(required)Number of children(required)Postal address(required)1. How did you hear about Sari's Natural Medicine?Word of mouthSari's Natural Medicine websiteGoogleNewspaperFlyerDr. L Wilson's websiteOther2. 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).123456789106. 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:(required)9. List any natural supplements, herbs and remedies you are currently taking:(required)10. List any medications you are currently taking:(required)12. Which, if any, natural practitioners are you currently seeing?(required)13. Please rate the following on a scale of 1 (poor) and 5 (excellent). General health and wellbeing12345Why have you selected this rating?Overall quality of your diet12345Why have you selected this rating?Sense of calm and relaxation12345Why have you selected this rating?Quality and quantity of sleep12345Why have you selected this rating?Exercise and general activity levels12345Why have you selected this rating?14. 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:12345Engage in regular exercise/ activity:12345Practice relaxation techniques on a regular basis:12345Modify your sleep habits:12345Have consultations to assess your progress:12345Thank you. I look forward to working together with you to help you reach your health potential.
