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Online Consultation

      version 2.5

This form is for you to use to request a consultation for yourself or on behalf of someone else - perhaps a child, friend, parent or loved one who would have difficulty doing it for themself. For this reason we have referred to the person who the consultation is for as a "patient" - this is simply to clarify the process of completing the form. In this form the use of the word "patient" does not infer anything whatsoever about any individual's legal or medical condition or situation.

I assure you that I treat this information with the same confidentiality and respect that I have for all my clients' information whether collected in my clinic or online. I will not use any of this information for any purpose other than to help me assess your health situation and to identify useful treatments or dietary regimes.

Trijntje Reilly


Please complete the form below as fully as you can,
 coloured fields show information that is necessary for me to effectively undertake the health assessment which forms the basis of the online consultation. The address fields are needed so that we know where to send any medicines should your condition require them.
 coloured fields are optional and can be left blank if you wish. If you move your mouse over the use your mouse to get a better idea of what information you need to provide you will see a tooltip explaining the information I need in more detail.



Your Details
Title
blank image for visual spaceFirst Name
Last Name
Gender
E-mail
Phone
Mobile
Birth date day     month     year   enter the day, month and year of your birth -  the year needs 4 digits - eg 1974 not just 74




Your Address Details
Address line 1
Address line 2
City or town
State Post Code
Country




Patient´s Details


blank image for visual spaceFirst Name
Last Name  enter your last name or surname here
Gender  indicate the patient's gender (sex)
Height  enter your height and the units of measurement eg 58 inches or 160 cms
Weight  enter your weight and the units of measurement eg 160 lbs or 70 Kg
Occupation  enter your principal job, work or occupation
Birth date day     month     year   enter the day, month and year of the patients birth date - please use numbers rather than names. The year needs 4 digits - eg 1974 not just 74
Blood Type   indicate the patients blood type if you know it
Marital status:   choose the marital status which best describes the patients current situation
Briefly describe your relationship to the patient:





Patient´s Health History Details

This information helps me develop a more accurate
picture of the patient´s health and wellness history


Describe any major illness the patient has suffered:
 indicate if the patient has ever suffered from a major illness, hospitalisation or debilitating condition -  including any childhood illnesses you are aware of

Describe any life-threatening experiences the patient has undergone:
 indicate if the patient has ever been in any kind of near-death situation where their life was seriously threatened - from conception onwards

Please describe any broken bones the patient has suffered:
including age and location in body (eg 3 years old - left wrist)
 indicate if  the patient has ever broken any of the bones anywhere in their body

Describe any aches or pains in their bones the patient experiences:
 indicate if  the patient is still experiencing pain or discomfort from the injury site/s
 Does the patient have a Family History of Cancer?
 indicate whether any members of  the patient´s family, any of their parents, grandparents or ancestors suffered or died from any form of cancer
 Does the patient have a Family History of Heart disease?
 indicate whether any members of  the patient´s family, any of their parents, grandparents or ancestors suffered or died from any form of Heart disease
 Does the patient have a Family History of Strokes?
 have any members of  the patient´s family,any of their parents, grandparents or ancestors suffered or died from any form of stroke



Patient´s Current situation

This information helps me develop a picture
of the patient´s current state of wellness.
All questions refer to the patient.

Please describe the patients diet in detail:
What does the patient have
for breakfast:
 What does the patient normally you eat for breakfast - include food and drinks


What does the patient have
during the morning:
 What does the patient eat between breakfast and lunch - include all food and drinks you normally consume


What does the patient have
for lunch:
 What does the patient normally eat for lunch - include food and drinks


What does the patient have
during the afternoon:
 What does the patient normally eat between lunch and dinner - include food and drinks


What does the patient have
for your evening meal:
 What does the patient normally  eat for dinner (evening meal) - include food and drinks


What does the patient have
in the evening:
 What does the patient normally eat after dinner before you go to bed - include food and drinks


What does the patient do for physical exercise?
 please describe what the patient typically does to exercise their body
How much time does the patient spend actively exercising per week?
 roughly how much time the patient spends exercising per week
Describe any Prescribed Medications the patient is currently taking:
 List any prescribed mediactions the patient is currently taking - including the name of the medication and the daily dosage
Describe any Vitamins and Mineral supplements the patient is currently taking:
 List any vitamin or mineral supplements the patient is currently taking - including the daily dosage
Describe any Herbal or Homoeopathic Medicines the patient is currently taking:
 Please list the herbal and/or homeopathic medicines and their dosages which the patient is currently taking on a regular basis
Describe any therapeutic treatment the patient is currently undergoing:
 Please tell me what therapy or therapies the patient yis currently undergoing and anything else you can add about their duration, frequency etc.
Please add any information here, in your own words,
which you feel would help describe the patient´s situation:



Symptoms

  This information also helps me develop
  a picture of the patient´s current state of wellness.

  Does the patient suffer from:




Payment Details
 
Do you want extended support?
 check this box if you want ongoing email-based or telephone-based support for your treatment for the next 6 months

Total Payment Amount: AUD$

Credit Card details:-
Credit Card type
Card Number
CVC Number
the number on the back of your card
how to find your CVC number.
Name on Card
Expiry Date Month     Year
Maximum Authorised Debit:  AUD$


Send your information now




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