Online Consultation Form


Before your first consultation, please fill in this online consultation form with your personal details, brief description of your chief problem and some basic information about yourself.

Feel free to skip any of the fields if they do not apply to you (e.g. in acute ailments) or those you do not wish to discuss.

For privacy reasons, the form is not stored in any database and is e-mailed directly to myself. After you have finished, click on the "Submit Form" button in the bottom of the form. You will receive a confirmation e-mail shortly.

Fields marked with * are required.


Personal Details

  Male   Female

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Contact Details


Home Address


Your Primary Medical Contact


Current Complaint

Can you describe what problem would you like treated *

Can you describe your medical history including past ilnesses

Please describe your symptoms as you experience them. What makes them better or worse?

How did your problems start? What was happening in your life at this time?

Are you experiencing any other problems? Do you experience them all the time or do they come and go along with the main complaint(s)?

What do you expect from the treatment? If you could choose, which symptom(s) would you prefer treated first? *

Please list known diseases of family members (skin problems, heart disease, high blood pressure, cancer, diabetes, mental illness, other)

Are you currently using any medication? Have you been using any prescription medication in the past?

About Yourself

Can you describe your current life situation? How do you feel about your current job, family, relationships?

Can you describe your digestive system? Do you have any food cravigs, aversions, allergies or intolerances?

How do you react to your environment? Do you prefer
  Being in hot/warm environment
  Being in cold/chilly environment
  You have no preference

How would you describe yourself in regards to other people? Do you prefer
  Being alone and/or by yourself
  Being in company of other people
  By yourself, but you want someone to be nearby
  You have no preference

Do you have any fears, phobias or nightmares you would like to discuss?

Can you describe your sleep? Do you have problems falling asleep? Are you waking up at night? How do you feel in the morning?

Do you smoke, use recreational drugs or drink alcohol? Have you been in the past?

Other

Is there anything else you would like to discuss?