Siobhán Shinnors – Licenced Medical Herbalist & Yoga Therapy
CONSULTATION FORM- NUTRITION & LIFESTYLE REPORT

Note: All records are strictly confidential under the patient client confidentiality agreement and are stored in compliance with data protection regulation.

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Name*
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Developed Allergies or Food Avoidances – List applicable

Tick applicable

BOWELS
BLADDER
MENSES
I use Contraception

Patients Medical History HIGHLIGHTS *

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Family Medical History


Heart

Cancer

Mental Health

Blood Sugar

Digestion

Rate yourself. 1 = Not Stressed / 10 Extremely Stressed
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Mind / Body

Iridology

Eye images info – both eyes should be sent. Image should be clear with only the iris and not the whites of the eye. Allowed file size : This can be done easily on most phones Attach photo of each eye – the file size must be less than 25 MB and the allowed file types are ( PDF & JPG )
Accepted file types: pdf, jpg, jpeg, Max. file size: 25 MB.
Accepted file types: pdf, jpg, jpeg, Max. file size: 25 MB.

Additional Documentation

Any recent/relevant Lab or Blood Tests can be attached here or info@yogaherbalist.ie. the file size must be less than 25 MB and the allowed file types are ( PDF & JPG )
Accepted file types: pdf, jpg, jpeg, Max. file size: 25 MB.

Diet – Give 2 Examples of each meal. Be as honest as possible. *

Breakfast

Lunch

Dinner

Snack

Drinks – List quantity per day/week in liters *

Thank you. This information will now be stored in your personal file and used during your scheduled online consultation. Any additional information can be added during the consultation.

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