Heilkunst Medicine Intake Form
Personal Information
Name (Last, First) *
Date of Birth (DD/MM/YYYY) *
Place of Birth
(City, Province/State/Territory, Country)
Mailing Address *
Please provide a current address where correspondence and/or remedies can be sent.
Email Address *
Phone Number
Please provide the best number to use for scheduling purposes and/or distance consultations
Skype Username
Therapeutic Objective
What would you like to change in your life? *
What are you willing to change? *
Who will you feel accountable to when making this change? *
Present State of Health
Present State of Health *
How would you describe your over all state of health? Consider some of the common indicators, including general disposition, energy level, quality of sleep, sex drive, appetite, and digestion. Please be as specific as possible.
Chief Concerns *
Please list 4-5 health concerns, which can be physical, mental, emotional, sexual etc.
Regimen
Sports/Exercise/Activities
Describe duration and frequency (ex. 1 hour of Core Yoga 2/week). Please Indicate if any of the activities are new to your routine (i.e. started within the last two weeks).
Current Supplements
Include dose, frequency, and brand (ex. 120mg of Vitamin C per day {SISU, buffered}).
Current Prescription Medications
Include dose, frequency, and brand.
Current Nonprescription Medications (ex. antacids, laxatives, pain relief medication)
Include dose, frequency, and brand
Current Recreational Drugs
Include dose and frequency (ex. 1 joint of cannabis 2-3 times a week; 1 line of cocaine 2-3 times a month)
Do you smoke?
If so, please describe dose and frequency (ex. 1 pack daily)
Do you drink alcohol?
If so, please describe dose and frequency (ex. 1 glass red wine 4-5 x week; 2 beers 2 x week)
Do you drink coffee and/or tea?
If so, please describe dose and frequency (ex. 2 cups of coffee, 1 cup of tea daily)
How much WATER do you drink daily?
This amount does not include water content in tea, coffee, or juice
Clear selection
Describe intake of other beverages
Include amount and frequency (ex. 2 glasses of orange juice daily, 1 can of pop 2-3 x week)
Blood Type
Your blood type can provide valuable information when selecting an optimal diet for yourself
Clear selection
Typical Diet
Please describe typical meals (including snacks) and approximate times (ex. oatmeal or toast or yoghurt and fruit for breakfast between 7:30-9am; vegetable salad or meat and cheese sandwich for lunch between 12-1pm; meat, vegetables, and rice or pasta for dinner, between 7-8pm)
What types of food do you typically crave and when? (ex. sweets when I'm low energy, chips when I'm stressed, fatty food all of the time)
How many hours of sleep to you typically get each night?
Please indicate if you work shifts and/or sleep during the day.
Do you feel this is enough sleep for you?
Clear selection
Family History
Please list any diseases and/or conditions that run in your family (parents, grandparents, siblings, aunts, uncles, cousins). Name the condition and the family member.
Ex. Lung cancer - paternal grandfather; heart disease - paternal grandmother
Informed Consent
I request and consent to participate in Heilkunst treatment with Carol-Ann Galego. I understand that no promise or guarantee of specific results can be made. I understand that each individual responds differently to treatment, and that all possible reactions cannot be anticipated.
I have read and understood the above consent for myself and/or the child under my guardianship. *
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