What would you like treating now?
i.e. pharmaceutical medication / natural medicines / therapies:
Please list any past conditions and the treatment required:
List any allergies:
List any vaccines in the past 5 years:
Do you smoke?
If yes, how many cigarettes a day?
Have you given up recently?
How many units of alcohol do you consume per week?
Are you a vegetarian?
Is there anything else you would like to contribute to this questionnaire?