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Submit Your Health Form

Before your consultation, please complete your health form using one of the following options:

Option 1:

Download & Fill PDF Form

Prefer pen and paper? Download the form, fill it manually, and upload it here once done.

Download PDF Form

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Upload Filled Consultation Form *

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Option 2:

Fill the Form Online

Save time by submitting your details directly through our secure online form.

Consultation Form

Name *

DOB *

Phone *

Email *

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

How did you hear about us?

Occupation

For Women: Are you pregnant?

Yes

No

Please check off any of the following where you experience pain or any conditions you suffer from:

Blood Sugar

Blood Pressure

Cholesterol

Liver

Heart

Kidney

Urinary Infection

Thyroid

Skin Problems

Arthritis

Depression

Stress

Metabolism

Allergies

Food

Seasonal

Pains

Joints

Kness

Arms

Legs

Shoulders

Back

Food

Belly Pains

R

L

C

Any other health conditions if you suffer from the following :

Constipation

Acid

Ht. Burn

Gas

Asthama

Nasal Blockage

Congestion

PND

Throat Itchy

Dry Throat

Eys/Ear Itchy

Sleep

Numbness

Neck Stiff

Hair Fall

Inflammation

Heat from Body

SOB

Energy Low

Palpitation

Weight Loss

Weight Gain

Concentration

Memory

Headache/Migraines

Vision-Reading

Driving

Hand & Feet Cold

List of Current Medications:

Any other health conditions not listed above? Please add below.

Which of the above is the worst?

How long have you been suffering or struggling with this condition?

How often does it occur? (daily, weekly, monthly?)

What is your pain on a scale of (1=mild, 10=severe)?

What have you tried that did not help?

How do you see your life in 3 years ifthe problem/s will get worse?

How would your life be if this/these problem/s will improve or resolve?

Does this cause you to suffer from?

Irritability or anger

Interrupted sleep

Restricted daily activity

Feeling frustrated or experience mood disorder

Fatigue

Decline in physical activity

Does this affect your life?

Holds me back from enjoying my family or friends

Affects my ability to work (or provide income)

Restricts my productivity or household duties

Prevents me from exercising or practicing sports

Interferes with my ability to enjoy my hobbies

I understand the purpose of the consultation is to better understand my health concerns. I understand that this consultation is not a medical evaluation or treatment and does not establish a provider-patient relationship.

Date

Signature

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Head Office: 604 593 5030
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