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Contact Details:

Sally Horrobin, Naturopathic Doctor
The Natural Root Wellness Clinic
11 Periton Lane
Minehead
Somerset
TA24 8AQ
Phone: 01643 707556
Email:

Once the form below has been completed and e-mailed to me I will phone you back within 7 working days.

Please use the following form to contact Natural Root.
Fields marked with * are compulsory.

First Name: *
Last Name: *
Gender:
Date of Birth: *
Address:
 
 
County:
Post Code:
Home Telephone: (please indicate best day to call)
Work Telephone: (please indicate best time to call)  
Email Address: *
Occupation:

A note to client: Please complete this questionnaire as thoroughly as possible in order to help me in understanding your complete health picture. This is a confidential health record and will not be released, except when you have provided me with written authorization to do so. Thank you.
 
Please list most important health concerns in their order of significance.Prior diagnosis of this problem? If so, what?Indicate painful or distressed areas:
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2
3
4
5
What goals do you have for your Naturopathic Medicine consultation?
Have you ever consulted a Naturopathic physician, an Acupuncturist, a Nutritionist or a Counselor before?
If Yes, how was your experience?
Do you have any questions about our clinic?
Please list prescription medications that you are currently taking, with dosages:
1 2 3
4 5 6
List vitamins, minerals, herbs, homeopathic remedies that you are currently taking, with dosages:
1 2 3
4 5 6
 
Press submit to send this form to Natural Root: