WHY YOU? FORM | CHARMAINE D | Advanced Skin Treatments & Naturopathy

‘WHY YOU?’ CONSULT QUESTIONNAIRE

Thank you for booking your ‘Why You?’ 30 minute, gifted to you, consult with Charmaine D.

Please fill out the following questionnaire prior to our consult.

We start the process with your free 30min consult. Then you can choose if you’d like to continue to working with Charmaine D with in-clinic or online sessions.

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Name *

First

Last

Date of Birth *

Phone

Email *

Preferred contact method:

Phone
Email
Text

YOUR CONCERN: What ailment/condition/concern are you wanting to address in this 'Why You'? consultation? *

YOUR SYMPTOMS: What symptoms are you presenting with?

MORE ABOUT YOUR CONCERN:

Is it ongoing?
Is it persisent?
Is it intermittent?
Is it slowing or beginning to stop?

What have you tried so far?

Were there any major events from birth till now that you feel could be involved in your current issue?

Are there any family members that have a history of similar events?

Where do you think your turning point may have been where your condition started? We will expand on this more in consult. Eg. NEVER BEEN WELL SINCE:

YOUR CURRENT HEALTH: What is your condition of health and have you been diagnosed with any medical issues past and present (the more detail, the better I can prescribe)?

Have you been diagnosed in past with any conditions by anyone? Or have you diagnosed yourself through self-investigation and, if so, what has been suggested?

* IMPORTANT: PRECAUTIONS * Please list anything I should be aware of before prescribing you a remedy. Eg pregnancy, breastfeeding, medical condition (such as heart disease, hypertension, diabetes) or any other medical or health conditions.

YOUR ALLERGIES: Do you have any of the following?

Food Allergies
Medical Allergies
Contact Allergies
Other Allergies

Please list your allergies (past and present):

YOUR MEDICATIONS: List any medications/drugs that you taking or have taken in the past. Including any recreational drugs or alcohol (please be as honest as you can, no judgement will be made)

Can you answer this WHY YOU? We will discuss this further in consult, it's just food for thought...

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