WELLNESS CONSULTATION QUESTIONNAIRE
This questionnaire is confidential, and you will not be judged by any of your responses. In order to gain the most out of your consultation, please answer all questions as truthfully as possible. If any questions do not apply to you, please LEAVE BLANK and do not fill out.
If you have had any recent laboratory testing, food sensitivity testing and/or hair analysis, please include all documentation with this questionnaire.
If you are taking any prescription medications, supplements or remedies, please include all documentation along with this questionnaire.
Please return this completed questionnaire to email: firstname.lastname@example.org at least one week prior to your scheduled appointment time; failure to do so will result in a fee of the full charge of the appointment.
o Initial Consultation Fee - $225 + Remedy Fee(s)
o Follow-up appointments are to be scheduled by each client approximately 1 month after your Initial Consultation; or sooner if preferred.
Blood Type – It is imperative that all clients provide their Blood Type (O, A, B or AB). If you are unaware of your blood type, please make the necessary arrangements to find out.
Your blood type may be found on your Long Form Birth Certificate, or Blood Donor Card. In some instances, your family physician may also have this information on file. Otherwise, please request (with your physician), a requisition for blood draw. Once you have obtained the requisition, you can then go to any lab for blood draw (ex. Life Labs). From this point, your results will be sent to your physician. It normally takes at least one week to obtain your results.