Welcome to our Health Questionaire

Please fill in each of the questions with as much detail as possible.

 

Please fill this form out for yourself
If completing for your child fill in the information relating to the child. You may want to add relevant information about yourself/family in the extra information field at the end of the form.
Supply an email address that is secure and confidential
Your present occupation and any relevant past ones
Describe the problem that you are seeking advice about?
Do you have any known allergies? Please list:
Medical History
Anything about your medical history that you think is relevant for us to help you.
Is there anything about your medical history that would be helpful for us to know
When was your last fever (high temperature)?
Have you suffered any major accidents or traumatic experiences?
What medications are you taking at present?
What have you tried up until now to help with this problem?
Your Childhood
Were you immunised as a child?
Did anything significant happen to you as a child?
Grandparents/Parents/Siblings - any relevant health information
Statistics
Enter these if you know them
cm
kg
Nutrition
Tick the foods you choose to eat.
List any food intolerances you have
Digestion
List any other digestive disturbances e.g. indigestion
Menstrual Cycle
Details of pregnancies and birthing
Sleep
Tick any that apply
Is there anything else you would like to briefly add to the information already given?
For NZ residents we often recommend other therapies so please give the city or town nearest to you.
Do you wish to make a booking for an in-store consultation with our Anthroposophic Health Practitioner. Fee is $20 for 20minutes. If so please supply a contact phone number.