Insomnia/Sleep Category - Page 6 of 6

Full name*

Age*

Date of birth

Gender

Male
Female

Occupation

Mailing address

Email*

Mobile number*

Existing Conditions

Hypertension*

Yes
No

Seizures*

Yes
No

Diabetes*

Yes
No

Heart Disease*

Yes
No

Liver Disease*

Yes
No

Kidney Disease*

Yes
No

Other*

Yes
No

Other details

Other Details

Do you have any allergies?*

Yes
No

Allergy details

Are you, or could you be pregnant?*

Yes
No

Are you breastfeeding?*

Yes
No

Current medications/supplements

What	When (am/pm)	How much (dose)	How long

Please list your main health concerns today

Consent*

I give my consent to be treated by: Natalie Connors (Adv.Dip.Nat/Adv.Dip.Lab.Tech.Path)

Risk & Liability
There are always possible risks to any treatment that is undertaken.
It is my responsibility to make you aware of such risks.
Possible risks to Treatment may include:-

reactions to herbal remedies or supplements

possible adverse reactions

fainting

headaches

tiredness

rashes/itching

nausea/vomiting

your condition may get worse before it gets better – this is the natural law of cure.

**If a reaction is severe please seek medical attention immediately.
**If any of these things occur please contact us for advice.
** It is your responsibility to advise us of any adverse reaction, so that we can advise appropriate action.
◦ Please keep in touch with us if there are any adverse changes, or things do not feel right.
◦ Stop taking any Remedies or Supplements immediately if you experience a severe reaction to them, and seek medical attention.
◦ Always take Remedies and Supplements as directed.

** It is your responsibility to remain open with all of your healthcare providers about any forms of medications, remedies, supplements, recreational drugs or alcohol you are taking.
◦ Sometimes these substances can interfere with each other causing them to work differently in your body than they normally do; they may not work at all, or they may work at an accelerated rate causing other adverse reactions.
◦ Some mixtures of medications may result in dire adverse reactions to one another.

It is important that you understand the risk involved in choosing to NOT openly share this information with your healthcare providers. We can not properly prescribe nor predict the consequences of a medication, if we do not have all of the information necessary. It is your responsibility to divulge this information.
Sharing this information is for your safety and best health outcome.

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