For example - chiropractic care, speech pathology etc.
Please include the drug name, frequency of dosing (e.g. once daily, twice daily) and dose amount (e.g. 10mg)
Please include the name of the supplement, frequency of dosing and amount of each dose (e.g one scoop, one capsule/tablet)
What are your current symptoms and how have those symptoms evolved over time?
Please provide a description of your dental history, including the number of fillings you have, whether they are amalgams or not and when (if applicable) your amalgams were removed.
Please list the vaccinations you have had. In particular, which vaccines have you had in the past two years.
Happy / joyful / stressful events / trauma
Have you ever lived/worked or currently live/work in a mould impacted environment? Did you grow up or work on a farm? Have you worked in mining?
Please detail what you generally have for breakfast, morning tea, lunch, afternoon tea, dinner and dessert.
What fluids, and the quantity of those fluids, do you consume each day? Please include alcohol consumption.
Are there further comments you wish to make in relation to your digestion?
Are there further comments you wish to make in relation to your hair/ skin / nails?
Are there further comments you wish to make in relation to viruses you may have experienced?
Are there any further comments you wish to make in relation to your cognition?
Are there any further comments you wish to make in relation to your current mood?
Please details the operations you have undergone
What exercise do you do each week?
What mindfulness / meditation practices do you undertake?
What do you do on a daily or weekly basis that brings you joy?
What joyful activities would you like to do on a daily or weekly basis, that you currently do not do?
Thank you for taking the time to complete this form. If there is any additional information you wish to share, you are welcome to do so in this space.
Test results such as stool testing, recent blood work, Organic Acids Testing etc. - Please email to jacinta@jacintaoconnor.com
