Health Questionnaire

Please complete this form in full before your appointment so we can make the most of our time together.

Bring your results

Please bring your recent blood test results and any other relevant test results or screenings to your appointment.

Pre-Appointment Health Questionnaire

Please complete this questionnaire before your appointment. Kindly bring your recent blood test results and any other test results with you to your consultation.

First Name*

Last Name*

Email Address*

Phone Number*

Date of Birth*

Day

Month

Year

Gender

Male

Female

Other

Prefer not to say

Medical History

Reason for Appointment*

Do you have any of the following conditions?

Diabetes

Hypertension

Heart Disease

Asthma

Allergies

Other

Current Medications

Have you had any recent surgeries?

Yes

No

Lifestyle & Wellness

How would you rate your overall health?

Do you smoke?

Never

Former Smoker

Current Smoker

Patient Signature*

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Tailored Therapy Natural Health

hello@tailoredtherapynaturalhealth.com

(64) 211107972 | hello@tailoredtherapynaturalhealth.com

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