Naturopath Practitioner Questionnaire

This is a medical consultation, and the naturopaths require the patient to be honest to ensure quality advice is provided.

Are you an athlete in a sport that subscribes to the WADA World Anti-Doping Code?*

Yes

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What products are you interested in? (Tick all that apply)*

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What are some of your Goals ?

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What do you expect to achieve?

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Do you have any blood tests done recently that will give us more information about you?

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Name*

First Name

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Middle Name

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Last Name

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Email Address*

Enter Email Address

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Confirm Email Address

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Address*

Your Address

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Zipcode

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City

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- select your country -

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Phone Number*

Phone Number

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Date of Birth*

dd/mm/yy

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Gender*

Male

Female

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Weight*

Your Weight

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Height*

Your Height

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Body Fat % (If known)

Your Body Fat %

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How often do you train or play sport (If none please specify) *

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Current Diet (Macros) - Protein / Carbohydrates / Fats (If Known)

Protein / Carbohydrates / Fats

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Daily Calories (If Known)

Calories

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Past Medical History

Have you ever been admitted to hospital in your life past or recent?*

Yes

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Have you had any form of cancer in the past?*

Yes

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Thyroid disease*

Yes

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Heart disease*

Yes

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Details of Admission

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Details of Cancer and remission

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Details of thyroid disease and treatment

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Details of heart disease and treatment

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Other

Other Details If Any

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Medications

Do you smoke?*

Yes

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Have you used APO Compounds before?*

Yes

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Add More

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Which products did you use, at what daily dose, for how long and when?

Products you used Before

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Current medications name

Medications Name

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Daily Dose / Frequency

Daily Dose

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Allergies

Do you have any allergies?*

Yes

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If Yes, Please provide details

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Medical Information

Agree*

I certify that all the information provided on this application is accurate to my knowledge

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Submit

Naturopath Practitioner Questionnaire