Questionnaire
Mr. /Ms. / Mrs.
Personal Status
Address
Birthdate
Do you have any children? If so please list their ages
Post Code
E-mail
Occupation
Phone / Mobile
Health Fund
Emergency Contact Information
Full Name
Relationshop
E-mail
Phone / Mobile
what is / are your main presenting condition/ Concern(s)?
Healthcare / Doctor Information
Full Name
Phone / Mobile
Clinic Name
Address
Do you have any known allergies (please list)?
List of Current Supplements / Herbal remedies
Supplement Name
Your HTML here...
Dosage / Per Day / Duration
Purpose
List of Current Medications
Medication Name
Dosage / Per Day / Duration
Purpose
How did you hear about Larissa?
Prescribed Disease / Conditions:
(i.e. Diseases / Conditions that should only be treated by, or in conjuction with, a western medical doctor) In accordance with the Health Practioner Regulation National Law (http://ahpra.gov.in/About-AHPRA/What-we-do/Legislation.aspx) non medical health practitioners can't claim the ability to cure or offer any service in the nature of a cure for certain conditions as follows:
- HIV / AIDS
- Multiple Sclerosis
- Hepatitis
- Poliomyelitis
- Cancer
- Epilepsy
- Tuberculosis
- Diabetes
- Leukemia
- SARS
Please note this is not a medical practice.
Electronic Signature
Latest Articles
From the dream of a baby… to the first snugglesI absolutely loved working with this couple in helping them create their dr...
Latest Recipes
Beautiful Breakfast BircherI love this breakfast. It is a healthy version of Bircher. Many of the Birc...
My Latest Feeds
Follow Our Blog
- From the dream of a baby… to the first snugglesI absolutely loved working with this couple in helping them create their dream family with their beautiful baby boy......
* GUEST POST * Guide to Sleep During PregnancyWhen you're pregnant, sleep is pretty important. Not only does it keep your own body healthy and well-rested, it's vital to the proper development of...