EVERYDAY AILMENTS QUESTIONNAIRE

If it is seen that an Everday Ailment Consultation is not correct for this situation of your ‘everday ailment’ we will advise you.

It is important that you are detailed and honest when answering the questionnaire below.

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Name
Preferred contact method:
MORE ABOUT YOUR AILMENT:
YOUR ALLERGIES: Do you have any of the following?

This form gives a quick overview of your health/condition. We will go into more detail by phone or in person.

Thank you for filling this out and returning to me promptly.