Pharmacy Consultation Form

Name*
First Name Last Name
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Have you ever had problems with any of the following? (Check all that apply)*
- Adrenals
- Allergies
- Anemia
- Anxiety
- Asthma
- Bleeding
- Breasts
- Burping/Gas
- Cancer
- Circulation
- Depression
- Diabetes
- Digestion
- Edema
- Fainting
- Fatigue
- Fibromyalgia
- Galbladder
- Heart
- Heartburn
- Headaches
- Hiatal Hernia
- High Blood Pressure
- Hypoglycemia
- Insomnia
- Kidneys
- Liver
- Low Blood Pressure
- Lungs
- Menopause
- Numbness in Hands or Feet
- Ovaries
- Pancreas
- PMS
- Prostate
- Skin/Acne
- Spleen
- Throat
- Thyroid
- Ulcers
- Weight
- Other
If other, please describe:
Do you eat out more than 5 times per week?*
- Yes
- No
Do you eat breakfast regularly?*
- Yes
- No
Do you eat fast food daily?*
- Yes
- No
Do you drink coffee on an empty stomach?*
- Yes
- No
Do you eat organic fruits and/or vegetables daily?*
- Yes
- No
Do you smoke?*
- Yes
- No
Are you currently pregnant, nursing or trying to become pregnant?*
- Yes
- No
About how many servings of refined sugar do you eat daily? (candy, pastries, most desserts, anything with syrup, malt, or words ending in -ose in the ingredients)*
About how many servings of processed carbohydrates do you eat daily? (most baked goods, pasta, white bread, soft drinks, etc.)*
About how many servings of dairy do you have per day?*
About how many servings of processed meats do you eat daily? (hot dogs, sausage, bologna, etc.)*
What is your occupation?*
Are you mostly active or mostly stationary during the day?*
How many hours do you work in a typical week?*
Do you exercise 3 times per week or more?*
Check any below that you regularly come into contact with at home or the workplace:
- Humidity
- Mildew
- Old carpet (4+ years)
- Smog
- Insect repellant
- Lawn chemicals
- Garden chemicals
- Chemical cleaning agents
- Poor ventilation
- High traffic areas
- Florescent lighting
- Air conditioning
Surgeries
List all surgeries and the cause (click the plus symbol to add multiple surgeries)
Year Surgery Cause
Allergies
List all food and medicinal allergies and a description of the reaction. (click the plus symbol to add multiple allergies)
Cause Reaction
Medications
List all medications and supplements you’re currently taking including prescriptions, over-the-counter, vitamins, etc. (click the plus symbol to add multiple medications)
Medication Strength Date Started Times per Day
Past Medications
List all medications previously taken in the last two years. (click the plus symbol to add multiple medications)
Medication Strength Date Started Times per Day
If there’s any other medication or medical history you think we should know about, please give us the details below.
Reason for Consultation*
Please use the space below to tell us about the reason for your visit and what you’d like to achieve from this consultation.
What days are you available?*
- Monday
- Tuesday
- Wednesday
- Thursday

Year	Surgery	Cause

Cause	Reaction

Medication	Strength	Date Started	Times per Day

Medication	Strength	Date Started	Times per Day

Consultation Form

Pharmacy Consultation Form

Contact Us