Pre-Consult Questionnaire

Please fill and submit the following form prior to your initial consultation. Your information is confidential and secure.


Legal Name *
Legal Name
Date of Birth *
Date of Birth
Phone (mobile preferred) *
Phone (mobile preferred)
DIET ANALYSIS
Describe your average meals (what you normally have). If you skip the meal often, please state that. Include any beverages.
Select the animal proteins that you DO NOT wish to eat *
HOW DO YOU FEEL?
Select a number on a scale of 0-10 from the drop-down list to identify how you feel (on average/normally) in each of the below areas. Please be realistic and do not exaggerate.
10 being the best
10 being the best (e.g. hours of sleep, wake up feeling rested?)
10 being the best (e.g. indigestion? gas and bloating? quality of bowel movements)
10 being the best (e.g. thinking sharp and not being forgetful)
10 being the best
10 being more stressed
10 being more hungry often
10 being more severe body aches and pains
10 being more mobile (e.g. walking up stairs with ease, joints are fine and breathing is fine while exercising)
10 being more moody
10 being the best
10 being the best (e.g. feeling of great pleasure, happiness and well-being of your overall life)
HEALTH AND LIFESTYLE GOALS
TAKE YOUR TIME ON THIS AND BE SPECIFIC. WHAT DO YOU TRULY WANT? THINK DEEPER THAN YOUR SURFACE DESIRES.
HEALTH HISTORY
Be sure to list any internal organs that have been extracted. E.g. gallbladder, liver, kidney, ovaries.
Please identify which side of the family (maternal or paternal) the conditions are on. Has anyone died from any health conditions (parents, grandparents, siblings, aunts, uncles etc.)
Please list what, how much and how often.
Please list what, how much and how often.
How Did You Hear About Us? *
If multiple, select those that apply
Legal Agreement *
I understand that providing incorrect information can be dangerous to my health. I will not rely on Primal Nation and their staff for information as a substitute for, nor does it replace, professional medical advice, diagnosis, or treatment. If I have any concerns or questions about my health, I should always consult with a physician or other health-care professional. Nothing stated or posted on this site or available through any services are intended to be, and must not be taken to be, the practice of medical or counseling care. For purposes of this agreement, the practice of medicine and counseling includes, without limitation, psychiatry, psychology, psychotherapy, or providing health care treatment, instructions, diagnosis, prognosis or advice. By checking the box, I confirm that I understand the above statements and that the questions on this form are true and have been accurately answered.