Siobhán Shinnors – Licenced Medical Herbalist & Yoga Therapy

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

Focus – What do you want to achieve from this consultation*
Describe your Symptoms*
Current medication / Supplementation (list dose & brand)*
Developed Allergies or Food Avoidances - List applicable
Conditions & Symptoms - Tick applicable*
Patients Medical History HIGHLIGHTS *
Family Medical History
Stress Level
Mind / Body
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 )
Additional Documentation
Diet – Give 2 Examples of each meal. Be as honest as possible. *
Drinks - List quantity per day/week in liters *
Drugs - tobacco / vaping / recreational drugs *
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.

Important Notice 

Please do not close this tab until you see the information that the form is sent. It may take a while, but this data is important so we appreciate your patience.