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HEALTH QUESTIONNAIRE

Please complete the questionnaire by answering as many questions as you can. Don’t worry if you can’t answer everything, the form is designed to highlight the areas you’d like to focus on during your appointment. There is no obligation to answer all of the questions, but the more detail you can provide the better I’m able to help you with your health concerns.

    Your Details
    1. Name
    2. Address
    3. Email
    4. Phone
    5. Date of Birth
    6. Doctor's name & address
    7. How did you find out about Alchemilla Apothecary?
    8. Would you like to receive our email newsletter?
    9. Please briefly describe the reason you’ve booked an appointment today
    Basic Health Information
    1. Blood Group (If Known)
    2. Do you have any allergies?
    3. What is your current weight? (if it is a concern)
    4. Do you have high or low blood pressure?
    5. Are you diabetic?
    6. Are you pregnant?
    7. Are you currently breastfeeding?
    8. Do you suffer with epilepsy ?
    Medication

    Please list any medications you’re currently taking (including any herbs or supplements), the length of time you have been taking them for, the current dose per day, and whether they are prescribed by a medical professional or self-prescribed

    Have you ever had an adverse reaction to any supplement and/or medication? If so please indicate which supplement, and the nature of the reaction

    Health Concerns

    Please list your main health concerns (physical, emotional or psychological) in order of importance to you, and how long you have had these issues

    What makes your condition worse / better?

    1. Have you tried any other therapies or dietary measures to help you get better?

    Medical History
    1. Were you born a healthy baby?
    2. Please list any vaccinations you can remember having (including travel)
    3. Please list any childhood illness you remember having (include approximate dates)
    4. Please tick any conditions you have suffered with either now, or in the past.
    5. If you selected 'Other' please list it here
    6. Please indicate if any close family members have also suffered with these conditions
    7. If you selected 'Other' please list it here
    8. When was the last time you saw a doctor? What was the reason?
    9. Have you recently had any medical tests or investigations?
    10. Have you ever had any of the following childhood illnesses?
    11. If you selected 'Other' please list it here
    12. Have you ever contracted a tropical disease?
    13. Have you ever had a serious head injury?
    14. In the last 10 years, approximately how many courses of antibiotics have you taken?
    15. What were these for?
    16. Have you ever spent time in hospital or had an operation? (Please list the reason and approximate dates)
    17. Please list any other serious medical conditions
    Stress Profile
    1. Is anxiety a problem for you? If so, are you generally an anxious person or is this a recent problem?
    2. How does this manifest / affect your life?
    3. Do you smoke?
    4. Do you drink alcohol?
    5. Is alcohol a problem for you?
    6. (Please be aware that you may be prescribed herbal tinctures which are alcoholic extracts. It’s important to let me know if alcohol is a problem for you so that I can adapt your medication accordingly)

    Sleep Profile
    1. What time do you naturally wake up?
    2. What time do you usually go to bed?
    3. Do you have a steady routine?
    4. Do you feel refreshed on waking?
    5. Do you ever have nightmares or bad dreams? YesNoSometimes
    6. How much exercise (and what kind) do you do in a typical week?
    Diet
    1. Do you follow a special diet (eg: vegan, halal etc)
    2. What are your favourite foods?
    3. Are there any foods you dislike or avoid?
    4. Do you have any known food allergies? (Please detail any tests you have had)
    5. Do you suffer with any of the following?
    6. Are there any foods in particular that you crave?
    7. How frequently do you have a bowel movement? (Eg: once a day)
    8. Is going to the toilet an issue for you (eg, urgency, frequency, getting up in the night…)
    9. How much water do you drink on average? (Eg: once a day)
    10. Have you ever been, or are you currently on a diet? (Please provide details)
    11. Do you have trouble gaining or losing weight?
    12. Do you ever have trouble concentrating, or do you experience “brain fog”?
    13. Do you, or have you ever experienced any of the following
    Skin
    1. Please indicate if you are prone to any of the following
    Immune System
    1. Please indicate if you experience any of the following on a regular basis
    Respiratory System
    1. Do you suffer from or have ever had any of the following conditions?
    2. Have you ever had any heart tests?
    Joint Health
    1. Please indicate if you suffer with any of the following
    2. Have you ever broken a bone?
    Female Only Questions
    1. Are your periods regular?
    2. How long do they last?
    3. Do you ever have spotting between your periods?
    4. Are your periods painful or debilitating?
    5. Do you easily gain weight during, or just before your period starts?
    6. Do you currently use contraception (eg the pill, the coil, intravenous?) Please list any brand names:
    7. Do you suffer with PMT?
    8. Please describe any symptoms
    9. Are you currently going through the menopause?
    10. Do you have any symptoms such as night sweats or hot flushes?
    11. Are you currently taking HRT? Please list the brand

    Thank you so much for taking the time and trouble to complete this questionnaire.  This will greatly help me to help you achieve your healthcare goals.

    I very much look forward to seeing you at your appointment.

    PLEASE NOTE: The information you provide on this medical assessment form is confidential and will not be discussed or shared with any third party unless absolutely necessary (e.g. GP) without your express consent.

    If you have any questions at all, please do feel free to contact me via email at sarah@alchemilla.co. I’m happy to help.

    Please do remember that I am herbalist and a naturopath, but I am not a doctor. I can’t prescribe allopathic medicines or make any diagnosis, but am happy to work with your GP for the benefit of your health.

    Although everything possible is done to ensure a positive outcome, like everything in life, there is no guarantee you will always achieve 100% success. Each patient responds differently to care. Your progress is based on many factors, including your commitment to making lifestyle changes, compliance with suggestions, and adherence to the treatment plan.
    By commencing treatment, you agree that I am not responsible for the success or failure of your treatment outcome.

    T’s & C’s

    HEALTH DISCLAIMER

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