Consultation Form

NAME*

First Last

How did you hear about us?*

e.g.. Google Search, Friend Referral, Yelp, etc.

ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GENDER (How do you identify?)*

DATE OF BIRTH*

PHONE*

EMAIL*

EMERGENCY CONTACT (First Name, Last Name, & Phone Number)*

HOW MANY TIMES PER WEEK ARE YOU PHYSICALLY ACTIVE?

WHICH TYPES OF ACTIVITIES?

HOW MANY OUNCES OF WATER DO YOU DRINK DAILY?

WHAT TYPE OF WATER DO YOU DRINK DAILY?

HOW MANY DIGESTIVE ENZYMES DAILY?

HOW MANY BREATHING EXERCISES DAILY?

WHICH DO YOU CONSUME DAILY?

WHAT TYPE OF FOODS DO YOU CRAVE?

Salty

Chocolate

Sweets

Breads

Other

WHAT ARE YOUR FAVORITE FOODS?

HOW MUCH DAILY ENERGY?

WHAT SURGERIES HAVE YOU HAD AND WHEN?

HOW MANY HOURS OF TV DO YOU WATCH DAILY / WEEKLY?

HOW MANY HOURS OF SPIRITUAL ENRICHMENT EACH WEEK? (Prayer, Meditation, etc.)

HOW MANY HOURS A WEEK DO YOU SPEND WITH FAMILY / FRIENDS?

HOW MANY HOURS OF SLEEP DO YOU GET EACH NIGHT? HOW MANY DO YOU NEED?

WHAT PRESCRIPTION MEDICATION(S) DO YOU TAKE?

DO YOU HAVE ANY KNOWN ALLERGIES?

AREAS OF CONCERN

DISCLAIMER*

The client fully understands that the alternative treatment is intended to support your health and wellness goals. The client has requested alternative therapies from “The Pure Rx.”

The client understands that alternative treatment is not a substitute for medical diagnosis, treatment, or advice from your health care provider. It is also recommended by “The Pure Rx” that all current medical treatments for any health concerns should continue to be followed up by their existing healthcare provider.

The client understands that alternative treatment is not intended to diagnose, treat, cure, or prevent any disease or condition.

The client understands the results of alternative treatment may vary from person to person and are not guaranteed.

The client understands that “The Pure Rx” is not responsible for any adverse effects or consequences that may result from your use of alternative treatment or from your failure to consult your health care provider.

I agree to cancel my appointment at least 48 hours in advance or pay a $50 cancellation fee. I also agree to pay the full consultation fee if I do not show up or call for my appointment.

I acknowledge that Dr. Mathew Jadan is a Naturopathic and not a medical doctor.

Cancer – Digestion – Fatigue – Sleep Apnea – Sickle Cell Anemia – Other Conditions