Confidential Health Questionnaire - Alchemilla Apothecary

confidential

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

Name
Address
Email
Phone
Date of Birth
Doctor's name & address
How did you find out about Alchemilla Apothecary?
Would you like to receive our email newsletter? Yes PleaseNo Thanks
Please briefly describe the reason you’ve booked an appointment today

Basic Health Information

Blood Group (If Known)
Do you have any allergies?
What is your current weight? (if it is a concern)
Do you have high or low blood pressure?
Are you diabetic? YesNo
Are you pregnant? YesNo
Are you currently breastfeeding? YesNo
Do you suffer with epilepsy ? YesNo

Medication

Please list any medications you’re currently taking (including any herbs or supplements)

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 in order of importance to you, How long have had these issues?

What makes your condition worse / better?

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

Medical History

Were you born a healthy baby? YesNo
Please list any vaccinations you have had (including Covid / travel)
Please list any childhood illness you remember having (include approximate dates)
Please tick any conditions you have suffered with either now, or in the past. AlcoholismAllergiesAlzheimersArthritisCancerDepression or other mental illnessDiabetesDrug abuseHeart diseaseHepatitisHIVOsteoporosis or arthritisStrokeOther
If you selected 'Other' please list it here
When was the last time you saw a doctor? What was the reason?
Have you recently had any medical tests or investigations?
Have you ever had any of the following childhood illnesses? Chicken poxMeasles or mumpsOther
If you selected 'Other' please list it here
Have you ever contracted a tropical disease?
Have you ever had a serious head injury?
In the last 10 years, approximately how many courses of antibiotics have you taken?
What were these for?
Have you ever spent time in hospital or had an operation? (Please list the reason and approximate dates)
Please list any other serious medical conditions

Stress Profile

Is anxiety a problem for you? If so, are you generally an anxious person or is this a recent problem?
How does this manifest / affect your life?
Do you smoke? YesNo
Do you drink alcohol? YesNo
Is alcohol a problem for you? YesNoIt Might Be

(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

What time do you naturally wake up?
What time do you usually go to bed?
Do you have a steady routine? YesNo
Do you feel refreshed on waking? YesNo
Do you ever have nightmares or bad dreams? YesNoSometimes
How much exercise (and what kind) do you do in a typical week?

Diet

Do you follow a special diet (eg: vegan, halal etc)
What are your favourite foods?
Are there any foods you dislike or avoid?
Do you have any known food allergies? (Please detail any tests you have had)
Do you suffer with any of the following? BloatingWater retentionThrushSalt cravingsSugar cravings
Are there any foods in particular that you crave?
How frequently do you have a bowel movement? (Eg: once a day)
Is going to the toilet an issue for you (eg, urgency, frequency, getting up in the night…)
How much water do you drink on average? (Eg: once a day)
Have you ever been, or are you currently on a diet? (Please provide details)
Do you have trouble gaining or losing weight? YesNo
Do you ever have trouble concentrating, or do you experience “brain fog”? YesNo
Do you, or have you ever experienced any of the following Trouble swallowingHeartburn / IndigestionUlcer (stomach or mouth)Nausea / VomitingDiarrhea / ConstipationBlood in stoolHemorrhoids

Skin

Please indicate if you are prone to any of the following RashesEczema or PsoriasisAcne/boils/lumpsItchingDryness or fungal conditions such as athlete’s foot / dandruff

Immune System

Please indicate if you experience any of the following on a regular basis Watery or blurry eyes“Floaters” in front of your eyesExcessive ear waxHay feverSinus problemsNose bleedsEar infectionsSwollen glandsThrushExcess mucous or phlegmFrequent coughsUrinary infections such as cystitisAnaemia (Iron deficiency)Easy bleeding or bruisingLymph node swelling (Pain under the arms or in the groin area)

Respiratory System

Do you suffer from or have ever had any of the following conditions? BronchitisPneumoniaPleurisyShortness of breathAsthma/wheezingPalpitationsSwelling of the anklesRaynaudsCold hands/feetVaricose veinsLeg crampsNumbness or tinglingFainting/dizzinessMemory lossSeizures / convulsions
Have you ever had any heart tests? YesNo

Joint Health

Please indicate if you suffer with any of the following Joint painStiffnessMuscle spasmsCrampsBack acheRepetitive Strain Injury
Have you ever broken a bone? YesNo

Female Only Questions

Are your periods regular?
How long do they last?
Do you ever have spotting between your periods? YesNo
Are your periods painful or debilitating? YesNo
Do you easily gain weight during, or just before your period starts? YesNo
Do you currently use contraception (eg the pill, the coil, intravenous?) Please list any brand names:
Do you suffer with PMT? YesNo
Please describe any symptoms
Are you currently going through the menopause? YesNo
Do you have any symptoms such as night sweats or hot flushes?
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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