Your First name (don't put your last name please)

Date of appointment

Age of the client

Weight(kg) Height(cm)

Brief description of the problem. (List the main symptom first)

What have you already done?

Medical history (surgeries, illness, including year if known)

Current medications

Vaccinations (adult & childhood) fill in years too if known.

Current supplements and vitamins (name and doses)

Allergies

Intoxicants: smoking? alcohol? drugs? if yes: how much?

Dental work: grey fillings (past/present), root canals?

Food: typical breakfast, lunch, dinner, snacks

Current and previous jobs

I accept that this information is sent via email to dr Gael.

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