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?*
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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 -
  • Åland Islands
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa (US)
  • Andorra
  • Angola
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda (UK)
  • Bhutan
  • Bolivia
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei
  • Bulgaria
  • Burkina Faso
  • Burma (Myanmar)
  • Burundi
  • Cambodia
  • Cameroon
  • Canada
  • Cape Verde
  • Central African Republic
  • Chad
  • Chile
  • China
  • Colombia
  • Comoros
  • Congo, Democratic Republic of the
  • Congo, Republic of the
  • Cook Islands (NZ)
  • Costa Rica
  • Croatia
  • Cuba
  • Cyprus
  • Czech Republic
  • Denmark
  • Djibouti
  • Dominica
  • Dominican Republic
  • East Timor (Timor-Leste)
  • Ecuador
  • Egypt
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Ethiopia
  • Falkland Islands (UK)
  • Faroe Islands (Denmark)
  • Fiji
  • Finland
  • France
  • French Guiana
  • French Polynesia (France)
  • Gabon
  • Gambia
  • Georgia
  • Germany
  • Ghana
  • Gibraltar (UK)
  • Greece
  • Greenland (Denmark)
  • Grenada
  • Guam (US)
  • Guatemala
  • Guernsey (UK)
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • Hong Kong (China)
  • Hungary
  • Iceland
  • India
  • Indonesia
  • Iran
  • Iraq
  • Ireland
  • Isle of Man (UK)
  • Israel
  • Italy
  • Ivory Coast
  • Jamaica
  • Japan
  • Jersey (UK)
  • Jordan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Korea, North
  • Korea, South
  • Kosovo
  • Kuwait
  • Kyrgyzstan
  • Laos
  • Latvia
  • Lebanon
  • Lesotho
  • Liberia
  • Libya
  • Liechtenstein
  • Lithuania
  • Luxembourg
  • Macau (China)
  • Macedonia
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Malta
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Mayotte (France)
  • Mexico
  • Micronesia, Federated States of
  • Moldova
  • Monaco
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Namibia
  • Nauru
  • Nepal
  • Netherlands
  • New Caledonia (France)
  • New Zealand
  • Nicaragua
  • Niger
  • Nigeria
  • Niue (NZ)
  • Norfolk Island (Australia)
  • Northern Mariana Islands (US)
  • Norway
  • Oman
  • Pakistan
  • Palau
  • Palestinian territories
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Pitcairn Islands (UK)
  • Poland
  • Portugal
  • Qatar
  • Réunion (France)
  • Romania
  • Russian Federation
  • Rwanda
  • São Tomé and Príncipe
  • Saint Helena, Ascension and Tristan da Cunha (UK)
  • Saint Kitts and Nevis
  • Saint Lucia
  • Saint Pierre and Miquelon (France)
  • Saint Vincent and the Grenadines
  • Samoa
  • San Marino
  • Saudi Arabia
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Slovakia
  • Slovenia
  • Solomon Islands
  • Somalia
  • South Africa
  • South Sudan
  • Spain
  • Sri Lanka
  • Sudan
  • Suriname
  • Svalbard and Jan Mayen (Norway)
  • Swaziland
  • Sweden
  • Switzerland
  • Syria
  • Taiwan
  • Tajikistan
  • Tanzania
  • Thailand
  • Togo
  • Tokelau (NZ)
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Arab Emirates
  • United Kingdom
  • United States
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Vatican City
  • Venezuela
  • Vietnam
  • Wallis and Futuna (France)
  • Western Sahara
  • Yemen
  • Zambia
  • Zimbabwe
- 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*
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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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Medical Background

DO YOU EXPERIENCE ANY OF THE FOLLOWING?
Profuse sweating at night*
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Unexplained weight loss or weight gain*
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Fevers / Flu like symptoms*
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No interest in eating / Loss of appetite*
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Any abnormal growth or lumps (including new beauty spots)*
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Exhaustion / fatigue*
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Current Medical History

Untreated / Uncontrolled diabetes mellitus*
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Untreated / Uncontrolled heart disease*
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Any form of cancer*
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Are you currently pregnant or breastfeeding?*
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Uncontrolled thyroid disease*
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Hypertension*
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Do you have any current medical or surgical problems?*
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Past Medical History

Have you ever been admitted to hospital in your life past or recent?*
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Have you had any form of cancer in the past?*
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Thyroid disease*
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Heart disease*
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Details of Admission
Details of Admission
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Details of Cancer and remission
Details of Cancer and remission
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Details of thyroid disease and treatment
Details of thyroid disease and treatment
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Details of heart disease and treatment
Details of heart disease and treatment
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Other
Other Details If Any
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Medications

Do you smoke?*
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Have you used APO Compounds before?*
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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?*
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If Yes, Please provide details
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Medical Information

Agree*
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Submit