General Health

Meridian Remedies - Patient Intake form
If there is a red asterix next to the question you must enter a answer to move on to the next question
Full Name*

First NameLast Name
Date of Birth*
Height*
Weight*
Occupation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
Health Fund
How did you hear about Meridian Remedies?*
MEDICAL HISTORY
Describe your main complaint (please elaborate on any issues you think may be important)*
Please list any other symptoms you have at this current time or that come and go*
What has been diagnosed (by M.D)?*
Have you experienced any surgeries or accidents that resulted in concussions or blows to the head, any motor vehicle accidents or any other type of injuries?*
Are you taking any medication? Please note all medications, herbs, vitamins and minerals you take, even if you take them only occasionally.*
Do you have any scars? Note location of all operation or injury scars (even minor ones)*
Do you suffer from a irregular heart beat or have a Pace Maker?*
Do you have any other implanted powered devices in you ?*
Do you have any current encapsulated infections like a infected tooth or abscess?*
Have you received a organ transplant or stem cell therapy?*
Click on any symotom you have
Do you ever feel depressed or anxious?
How is your Sleep?
Are you a vegetarian or a vegan?*

NeitherVeganVegetarianOther
Appetite*

StrongWeakAverageNo appetite
Thirst and fluid consumption*

Strong thirstThirst but no desire to drinkWeak thirstDrinks a lotOther
Pain*

NoneEverywhereLocalised
Please specify intensity and location
Urination*

NormalCopiousA littleAssociated discomfortDarkYellowClearCloudyAt nightOther
Do you open your bowels everyday? Are the stools hard to pass or soft or normal? Do you ever have diarrhea or bloating?*
Menstruation

PainPMTClottingRegularIrregularAssociated with constipationLoose stools at onset of periodAssociated with headacheAssociated with loss of energyOther
Energy*

NormalFluctuatesAlways lowNot enoughEasily tiredUnable to relaxHigh
Sex drive*

NormalHighLow
Are you pregnant?*

YesNoUnsure
Should be Empty:

Meridian Remedies - Patient Intake form