Hi,
Please fill in this intake before the appointment.
First appointment: fill in all fields.
Recurrent appointments: only until the 'What have you already done' field

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

Date of appointment*

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

What have you already done?*

Age

Weight(kg), Height(cm)

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

Current medications

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

Current supplements and vitamins

Allergies

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

*Mandatory fields

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