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New Patient Registration

First Name
Middle Name
Last Name
Phone Number
Date of Birth
Height
Weight
Occupation
Street Address
City
State / Province
Postal / Zip Code

Medical History

Primary health concerns
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Onset of condition
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Taking any medications, currently?
If yes, please list it here
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Treatments that were effective
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Treatments that failed
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Any family members with similar symptoms
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Have you been diagnosed medically?
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Are you currently on any medication for this condition? If so, please state
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Can you think of anything that makes your condition better or worse? Please state
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Can you think of anything that makes your condition better or worse? Please state
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Do you have any other diagnosed illnesses?
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Is there a family history of above?
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Do you have any food allergies? If so, have they been diagnosed medically?
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Do you have any food allergies? If so, have they been diagnosed medically?
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Are you currently on any supplements? If so, please list, strength, frequency and brand. Who recommended them?
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Can you please describe a typical days eating pattern, including approximate times?

Breakfast
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Lunch
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Dinner
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Snacks
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Are there any foods you crave?
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Are there any foods you dislike?
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Do you drink alcohol? If so, how frequently?
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Do you drink coffee/tea? If so, how many per day?
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Do you drink Herbal teas? How many per day?
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Do you drink water? How much per day?
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Do you eat wheat products e.g. bread, pasta, cakes, biscuits, Weetabix, muesli? If so, how often? Give a day’s wheat eating pattern for Breakfast, Lunch and Dinner.
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Quality of sleep?
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Do you fall asleep immediately?
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Do you wake refreshed?
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Do you usually recall dreams?
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How is your memory / concentration?
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Do you smoke cigarettes? If so, how many per day?
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Do you exercise? What/how often?
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What do you do for relaxation?
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Hobbies?
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Do you function well under stress?

Digestive Health

Appetite?
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Weight fluctuations?
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Flatulence / bloating?
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Indigestion / reflux heartburn?
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Abdominal pain?
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Nausea / vomiting?
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Constipation, frequency?
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Diarrhoea, frequency?
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How often do you go?
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Size and shape of stool?
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Do your stools sink or float?
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Do your stools flush away easily?
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Female reproductive health

Age at onset of menstruation
How long is your cycle?
Duration of period in days
Heavy / light periods?
Irregularity, cramps?
PMT, bloating cravings,breast tenderness? If so, please detail.
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Mood swings?
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Thrush? If so, How often?
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Menopause, age? S&S: Hot flushes, palpitations, mood swings
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Endocrine health

How are your energy levels?
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Are you a cold or warm person?
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Do you feel shaky, faint, irritable if you miss a meal?
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Do you often get sleepy after meals?
Do you have any skin tags (Little tags of skin often found under arms, face, neck)?
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Do you crave salty foods?
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Inability to gain or lose weight?
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Please tick the symptoms or traits that apply to you:
Any other information you feel might be relevant to your health concerns
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BOOKING A SESSION

Would you prefer to meet in person in Dublin, Cork, or over Skype?
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Which days of the week suit you best to meet?
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Morning, Afternoon or Evening?
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Your Time Zone
Anything else you’d like me to know before we arrange our session?
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The information given in this form will be treated with the strictest confidence.

I will appraise the information given and will formulate a treatment plan for your specific health condition based on this information.

We may enter into some email dialogue with you if further information is required.

If you are being medically treated, our nutritional treatment plans are designed to work along side your prescribed medical treatment.

Before embarking on any new exercise or diet regime you should always consult with a qualified physician.

If you have any medical conditions, allergies or injuries, you should make both your doctor and nutritionist aware of them.

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