Your Initials (don't put your name please)

Date of appointment

Age of the client

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

Allergies

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

Δ