Name *First and Last nameEmail Address *Phone *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweDate Of BirthGenderFemaleMaleHEALTH GOALS - Please Provide a Brief Explanation of the Health Goals you would like to work on or the health concerns you have. *FAMILY HISTORY - Are there any major health concerns or recurring health issues within your family?MEDICAL HISTORY - Have you ever had any major surgeries or illnesses, or been hospitalised?Have you had diagnostics of blood tests carried out for this condition or recent testing?YesNoPlease upload any recent blood tests, diagnostics or reportsChoose FileNo file chosenDelete uploaded fileEXERCISE - How often do you exercise per week?0-11-23-45 or moreWhat exercises you enjoy?Do you drink alcohol?YesNoDo you smoke? this includes; vapes, e cigarettes and shishaYesNoDo you use recreational drugs?YesNoHow often do you experience colds/flus/viral infections?Do you experience cold sores?YesNoDo you have a history of antibiotic use?Please list any medications and or supplements that you are currently taking. Please list why prescribed.Have you traveled abroad and contracted traveller's diarrhoea? Food poisoning, parasite, tummy bug?Please select the areas of health you would like to address.Weight lossImmunityDigestionThyroidViral infectionsPeriod healthCardiovascular healthHormone healthSkin healthAllergiesIncreased energyselect all that applyPlease select any symptoms you are experiencing from the listProstate issuesGroin painErectile dysfunctionPeriod painPMSPMDDHeavy menstrual bleedingBreast tendernessUterine fibroidsLoss of libidoPCOSEndometriosis/AdenomyosisMenopauseHysterectomyHot flushesAbnormal cervical screeningThrushUTI'sIUDConstipationDiarrhoeaIBSCoeliac DiseaseUlcerative colitis/crohnsRefluxBloatingExcessive flatulenceFatty liverH.pyloriAbdominal painAllergiesIntolerancesMouth ulcersSinusesCold soresAsthmaEczemaRecurring infectionsMultiple antibiotic useBrain fogCold hands and feetPoor memoryDifficulty concentratingHeadachesThyroid illnessAnxietyDepressionSuicidal thoughtsExcessive hair lossHigh cholesterolDiabetes type 1Diabetes type 2Insulin resistanceHeart palpitationsShortness of breathHigh blood pressureFatigueAcneNauseatick all that apply/are recurring/concern youBREAKFAST: Please provide and example of a normal days breakfast and time eatenLUNCH: Please provide and example of a normal days lunch and time eatenDINNER: Please provide and example of a normal days dinner and time eatenSNACKS: Please provide and example of a normal days snacks and time eatenHow many cups of water do you drink on a standard day?How many Coffees do you include on a standard day?How many teas do you include on a standard day?How many other drinks do you include regularly?DISCLAIMER/CONSENT: I declare that the information that I have provided above is true and correct and indemnify Prudence Matar and Matar Health Holistic Nutrition and Wellness Clinic of any liability for any false and misleading statements given. I understand that treatment received from Prudence Matar and Matar Health Holistic Nutrition and Wellness Clinic is complementary allied health and does not attempt to diagnose or treat disease. I understand that the information collected is private and confidential and will never be shared with anyone unless solely requested by you for furthering your care. This form is not stored on the web portal and is deleted as soon as soon as it is submitted. Matar Health Holistic Nutrition and Wellness Clinic, does keep your information that has been given to us that is needed for your health care and consultation in your secure file and this may be stored on a secure cloud device for future access to your notes to aid in your health care. This information remains the property of Matar Health Holistic Nutrition and Wellness Clinic. I may request a copy of this information, for the purposes of further medical care. Requests must be made in writing.I agreeI decline to continueSubmit FormPlease do not fill in this field.
