Full Name * Date of Birth * Address * Email * Phone * Referred by* Briefly describe the conditions about which you would like to consult me * Vaccinations and any reactions Details of current medication Details of your health history: Include pregnancy, birth, childhood diseases, accidents, surgical procedures, shocks and traumas Details of alternative therapies, vitamins or supplements Allergies, past and present Have you had any chemical or toxic exposures Details of close relative's illnesses Current Health Care Practitioners