Appointment Form – Family Appointment Name(Required) First Last Email Address(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Family AppointmentSelect One:(Required) Single Patient Couple Family Age/s/Male/Female With Full Names(Required)Have you seen a Naturopathic Doctor before?(Required) Yes No What are you wanting to achieve?(Required)Blood pressure/s (if known)(Required)Weight/s(Required)Attach medical records (if you have any) Drop files here or Select files Max. file size: 2 MB, Max. files: 5. Stress Levels(Required)Please enter a number from 1 to 10.Do You Have Anger Issues/Outbursts?(Required)What Stresses You The Most?(Required)How many hours/days a week you work?(Required)Please enter a number from 1 to 80.Have you had any heart attacks or strokes?(Required) Yes No How many Heart Attacks(Required)How many Strokes(Required)Do you have issues with breathing or getting a deep breath?(Required)Do you exercise regularly? How and how often?(Required)Are you motivated to exercise?(Required)Do you have root canals/implants or silver fillings?(Required)How many hours of sleep at night? - Any issues with sleeping?(Required)What do you eat mostly throughout the week? - Good foods and bad.(Required)How much alcohol do you consume a day/week?(Required)Do you smoke? - How many a day and how many years(Required)Your Fitness Level(Required)Please enter a number from 1 to 10.Medical history. History of illnesses - (List all you can think of).(Required)List any medications you are taking and for what. (try to list them all and how long you have been taking them). Do your medications or supplements ever cause you unusual side effects or problems?(Required)Vaccinations? - List all vaccines you have taken and when.(Required)Do you have or had prolonged or regular use of NSAIDS (Advil, Aleve, Motrin, Aspirin, Tylenol etc.)?(Required)Have you had frequent antibiotic use?(Required)Do you bloat after meals and/or have a lot of gas?(Required)Do you suffer from cramps? - Where within the body?(Required)Any allergies?(Required)How much pure water a day do you drink?(Required)How many coffees/teas and soda do you drink each week?(Required)How often do you have bowel movement? (What color are your stools? - Medium brown, very dark or black, greenish, is blood visible? dark or light color)(Required)Any Pain? - (Share what type of pain and where)(Required)The whites of your eyes - (Are they, pure white, spots, yellowing?)(Required)Any exposure to chemicals?(Required)Live or lived in moldy homes or exposed to mold?(Required)Do you consume organic food? Use organic products, shampoo etc.?(Required)Your concerns - (List them all with symptoms)(Required)What do you love doing in your spare time?(Required)Select which one suits your situation. Due to many needing our help we need to help the most urgent cases first. So if your need is low or normal wait time kindly let us know by ticking this below. Let us be kind to each other. We will acknowledge your requests within 48 hours excluding weekends.(Required) Low Priority Normal Priority High Priority No Refund Consent(Required) I agree to the no refund policyI agree not to seek a refund from my credit card company for this service. That I have full knowledge of the payment I am making and I cannot request a refund from my credit card company. By ticking this box I am in agreement.Total hCaptcha(Required)
