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?

Other
Appetite
Thirst and fluid consumption

Other
Pain
Please specify intensity and location
Urination

Other
Do you open your bowels everyday? Are the stools hard to pass or soft or normal? Do you ever have diarrhea or bloating?
Menstruation

Other
Energy
Sex drive
Are you pregnant?
Should be Empty:

Meridian Remedies - Patient Intake form