Initial Consultation Form.

Please ensure you fill this out and submit at least 1 week prior to your appointment. 

Name *
Name
Emergency Contact
Emergency Contact
Please provide information about the following, including the year/your age at the time of illness/injury
biochemical
Do you eat/drink the following: *
EMG
Self Stress Test *
Self Stress Test
Please note: "Strongly Disagree = Not Often" and "Strongly Agree = Often".
How often do you experience stressful situations?
How often do you feel tired or fatigued for no apparent reason?
How often do you get less than 8 hours sleep?
How often do you feel anxious or depressed?
How often do you feel angry or aggressive?
How often do you feel self conscious or inadequate?
How often do you feel overwhelmed or confused?
How often is your sex drive lower than you would like it to be?
Do you tend to gain weight easily?
Are you currently dieting?
How often have you tried to control your body weight?
How often do you pay close attention to the foods you eat?
How often do you crave carbohydrates (sweets or breads)?
How often do you experience difficulty with memory or concentration?
How often do you experience tension headaches or muscle tightness in the head/jaw/neck or shoulder areas?
How often do you experience digestive problems such as gas, bloating, ulcers, heartburn, constipation or diarrhea?
How often do you get sick/ catch a cold/ flu/ sore throat?
Do you have high cholesterol (greater than 200mg/dl)?
Do you have high blood sugar (greater than 100mg/dl)?
Do you have high blood pressure (greater than 140/90 mmHg)?
Do you suffer from... *
Would you like to receive monthly emails from Bend Like Bamboo for SPECIALS? *
Please answer the following questions for our natuorpath/ nutritionist damian brown: