Consultation Form

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Consultation Form

Thank you so much for booking in with me – I am really looking forward to connecting with you and getting you to feel better.

In order for us to make the most of our time together, please complete this form as fully as possible.

You should aim to invest as least 15-20 minutes of your time to complete it.

Some of the questions may not seem relevant but are really helpful for me to help you so the more detail you can give me the better. All the information you provide is kept securely and in the strictest of confidence.

All the fields should be completed but if they are not relevant please put N/A.

If you have any relevant blood test results please do email me these to emma@themenopauseherbalist.com.

Step 1 of 3

Patient Information
Name
First Last
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Contact Number
Email
Date of Birth
Age
Emergency Contact Name
Emergency Contact Phone Number
What are your treatment goals?
How did you hear about the clinic?

Medical History/Lifestyle Questions
Can you provide a brief overview including dates of your medical history, for example any illnesses or surgeries requiring hospitalisation or chronic / acute illnesses you are receiving medication or treatment for:
Please provide details and results of any tests you have had in the last year ? Blood, salvia tests or investigations ?
Please list any medications (including contraception or coil etc) you are currently on detailing the dosage:
Please list any supplements or vitamins you are currently taking:
Do you smoke ? If so how many cigarettes per day ?
Do you drink alcohol ? If so how many units per week ?
Describe how much exercise you do each week ?
How would you describe your diet ?
How would you describe your energy levels ?
Are there any particular times of day when you feel very tired or very energised ?
Do you have any headaches ? If so please describe frequency, type of pain and location on head.
Do you have any ear or hearing issues ? including tinnitus (ringing in the ears), pain or infections.
How would you describe your mood ? Do you suffer from depression ? Do you easily get angry ? Do you worry or suffer from anxiety or mania ? Are you experiencing any mental fogginess or trouble thinking clearly ?
How would you describe your sleep ? Is it easy for you to fall off to sleep ? Do you wake in the night (is it at the same time ?) please detail the typical time you go to bed and wake up ?
Do you dream a lot ? Are they vivid dreams ? Nightmares ?
How would you describe your general / normal body temperature ?
Do you suffer from hot flushes ? Please detail their frequency and whether during the night or day ?
Do you experience night sweats ? Are they throughout the month or only at specific times ?
Do you suffer with any skin conditions ? Dry, itchy, red, pale, spots ?
How is your digestion ? Do you suffer with bloating, gas, nausea, pain, acid or heart burn ?
Do you have regular bowel movements ? Do you suffer from constipation or diarrhea ?
Do you suffer with urine tract infections ? Do you experience bladder pain ? Do you go to the loo at night ?
Do you experience any heart or chest, palpitations, panic attacks, low / high blood pressure ?
Do every experience any dizziness ?
Do you experience cold hands and feet ?
Do you have allergies or asthma ?
Do you every have floaters in your eyes (black spots or strings) ? do you suffer with dry and / or blurry eyes ?
Are you anemic or think you may be anemic ?
Please describe any areas of pain / concern on body ?
If you have a monthly cycle, please describe frequency, flow and length of bleeding ? Do you have any spotting or break through bleeding ? Describe any PMT symptoms you experience ?
If you no longer have a monthly cycle, please detail when it stopped ?
Do you suffer from vaginal pain, dryness or itching ?
Please give details of pregnancies and birth details ?

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