• Female Client First Time Evaluation Form

    Angela Frieswyk, Medical Herbalist & Holistic Nutritionist, Tauranga

  • Please Note the following:

    1. Prior to your very first consultation, could you please fill-in this form and send it to me by clicking on the Submit Button at the bottom of the form.
    2. Allow a good 10-15 minutes to complete the form.
    3. Some questions on this form are marked as "required" by showing a red asterix to the right of the question heading. You will get an Error Warning in a red box at the top of the form if you have not answered all the required questions. Please enter your answers for each of the required question, then press the blue Next Button.
    4. At any time while completing this form, you can step backwards through the various sections by clicking on the "Back" button at the bottom of each section of the form. You can make changes on what you have already entered. Likewise, you can move forward through the form by clicking on the blue "Next" button.
    5. All information entered by you is kept strictly confidential. The detail is used to allow me time to review your health basics and focus on priorities during your consultation.
    6. If you have any recent/relevant blood tests or medical reports, please bring these with you (request a copy from your doctor’s clinic or specialist). As an alternative, you can electronically attach these reports at the end of this form.

  • Your Personal Details:

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  •  -
  • Format: (000) 000-0000[0].

  • Your Health

    Current complaints/symptoms, Medications, Supplements, Surgery & Dental Work

  • Your Medications/Supplements

    Enter details on all your Medications, including birth control pills, pain medications, laxatives, etc. When listing your medications, please include the following details for each medication:

    1. Medication name
    2. Dose
    3. How long you have used it
    4. Why it was prescribed (if known).

  • Surgery History

    Please list any surgery procedures you have had and the time period in years or months or weeks since you had this surgery.

  • Dental Work

    If known, please provide details on the number of silver fillings, composite fillings, root canals or other dental work you currently have. Also note if you have current dental problems that need attending to

  • Cigarette Smoking, Alcohol Consumption & Recreational Drugs

    Please answer these questions if you are or have been a cigarette smoker.
  • Current Smoker*
  • Ex Smoker

  • Alcohol Consumption

    Please answer these questions if you drink alcohol
  • How often do you drink alcohol?*

  • Recreational Drugs

    Please only answer the following questions if you use any Recreational Drugs. Any information provided will be kept strictly confidential.

  • Sleep Questions and Stress Levels

  • Sleep Related Questions

  • How is your sleep? Select options that describe your sleep patterns.*
  • What time do you usually go to sleep?*
  • What time do you usually awake?*
  • Is your bedroom Dark or Light?*

  • Your Stress Levels and Reasons for Stress

  • Family Illnesses

    Please provide details on any illnesses in the immediate family.

  • Digestive, Bowel & Urination Health

  • Which of the following best describes your digestive health/symptoms. You can make multiple selections:*

  • Bowels Motions Questions

  • Bowels Motions Questions*
  • Stool Amount:*
  • Stool Consistency:*
  • Stool Colour:*
  • Other Stool Issues. You can make multiple selections:*

  • Urination Questions

    How are your daily urination's?
  • Urination problems?*
  • Do you need to get up out of bed & urinate several times over night?*

  • Menstruation, Menopause and related Questions

  • Are you pregnant?*
  • Are you breastfeeding?*
  • Are your monthly periods regular (around 28 days cycles)?
  • Symptoms experience associated with your period. You can make multiple selections
  • Do you have children?
  • Have your periods stopped?*
  • Have you had a Hysterectomy?*

  • Exercise Questions / Working Life Questions

  • Do you exercise?*

  • Dietary Questions – Please Answer

    Please provide details of a typical day’s diet

  • Main meals

    Enter the number of main meals you consume per week out of the following:

  • Beverages

    Enter the number of drinks you consume per day.

  • Other Dietary Questions – Please Answer

  • Diet preferences/habits - Tick boxes that best describes your diet (you can tick more than one as required):*

  • Appointment Day Preferences to meet with Angela

  • Please select your preferred day*
  • Time of Day for Appointment?*

  • Attach Medical Reports and Images?

    Please attach any Recent/relevant blood tests or medical reports you may have that are relevant to your appointment with Angela. You can also use the file uploads facility to upload images/photos of a condition you may have e.g. skin infection. File types allowed: pdf, doc, docx, xls, xlsx, rtf, zip, jpg, jpeg, png. Maximum upload 20MB.
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  • Please Note:

    You can step back through the form if you wish to check on any details you have entered by using the "Back" Button at the end of each section, likewise you can press the "Next" Button to step forward through each section.

    If you have entered all the required information correctly including the anti-spam check, you can press the green Submit Button.

    You will know if everything is in order and that the form you have just completed has been sent to Angela if you get a Thank You message from her.

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