EZY Script (free online health evaluation)

Looking to purchase a prescription only supplement and don’t have a script? No problem

Simply fill in our free online health evaluation and our online Naturopath will call or email you to discuss your health in order to write you an EZY script! (Please turn around time for a response in 24-48 hours). Once your script has been received, please upload the script when you purchase your product.

Please note for complex health conditions it is recommended you book a consultation with our Naturopath to ensure your health gets the necessary attention it deserves!

Surname*:

Given Names*:

Date of Birth*:

Age*:

Sex*:

MaleFemale

Address*:

Suburb*:

Post Code*:

Phone:

Bus:

Mobile*:

Email*:

Occupation:

Who is your family GP?

Do you see any other health practitioners?: (chiropractor, Specialists etc):

Have you ever consulted with a Naturopath or Natural Medicine Practitioner before?, if so when?

Are you Currently on Medication if so what type?

Do you take supplements? (vitamins, herbs etc)

Do you have any known Allergies?

YesNo

What type?

What is your main health concern?

How long have you had this problem?

What makes symptoms better or worse?

What prescription supplement are you wanting a script for?

When did you last feel well?

Do you use recreational drugs/alcohol, cigarettes?

How much caffeine do you consume?

Do you exercise?

YesNo

Please specify what type how often?

How much stress do you have? Scale of 1-10

Do you sleep well?

How many hours?

How is your energy? Scale of 1-10

What is your blood type?

I hereby acknowledge that the information given above or in clinic is given to the best of my knowledge and that my personal health information is kept strictly confidential unless the patient displays behaviour towards self-harm or a child’s safety is compromised. As a patient I also agree that it is my responsibility to give details as accurately as possible. I also agree to disclose information on previous and current illness. I understand that Integrative Practitioners provide health management based on correct information given.
I also understand that a cancellation fee applies for late cancellation (within 24 hours) or nonattendance as this may prevent others from receiving treatment.

Signature:Use your touch screen or mouse to sign

Date:

Print name:

EZY Script (free online health evaluation)

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