Welcome to The Modern Herbal Apothecary Consultation Form

Please fill out the form below to book a consultation with one of our Naturopaths.

This is the form that clients will fill out for a consultation

"*" indicates required fields

Step 1 of 4

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First Name*

Last Name*

Phone Number*

Occupation*

Email*

Date of birth*

MM slash DD slash YYYY

Date*

MM slash DD slash YYYY

Please list the main reason(s) for your appointment:*

What do you believe this problem may be due to? How long have you suffered with this issue?*

What kind of treatments have you tried for the problem(s) listed above? Please detail any relevant testing or investigations.*

What three things would you like most improved about your health over the next few weeks?*

Do you have any existing medical conditions or injuries, if so please list:*

Are you currently taking any herbal medicine or supplements, if so please list dosage and brands.*

Are you currently taking any medicines (eg. Pain relief/contraceptive pill) Please list dosage, brand, quantity)*

Do you have any known allergies or intolerances (dairy, gluten, penicillin)?*

How many days a week do you consume alcohol? How many drinks?

Do you Smoke?*

Yes

Do you suffer from any IBS symptoms? (constipation, Diarrhea, bloating, or gas) If so, are you treating it?*

Do you suffer from reflux? If so, are you treating it?*

How would you rate your current energy levels? (please select an option)*

0 – 2 (hard to get out of bed)

3 – 4 (feeling sluggish but functioning)

5 – 7 (could feel better)

8 – 9 (feeling good most of the time)

9+ (feeling amazing! Bursting with energy)

Is there any time throughout the day you feel a drop in your energy levels?*

How many hours of sleep would you have each night (on average)*

How would you rate your daily stress levels? Out of 10 (10 being very very high)*

What do you do for exercise? And how often?*

Is there anything else you would like me to know?*

Please email this form and any recent pathology tests (blood tests and medical tests) through to info@themodernherbalapothecary.com prior to your consultation.

Health and Happiness,

Jo