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Naturopathy Intake Form

First name

Last name

Email

Phone

Age

Weight

Blood Pressure

Heart Rate

Body Temperature

Are you currently pregnant?

yes

no

Do you have a pacemaker?

yes

no

Recent blood tests / full blood count results

What brings you to this consultation? Your main health concerns and expectations

Since when?
Treated how? (medications, supplements)

Describe your health history (childhood, adolescence, adulthood)

Digestive issues?
Learning / concentration problems?
Frequent infections? Antibiotics?
Past/current headaches?

Do you have sleep problems?

yes

no

Do you need to urinate during the night?

yes

no

Do you have pets at home?

yes

no

Do you experience joint pain? If yes, at what time of day?

Are you physically active?

yes

no

Do you often feel tired without a clear reason?

yes

no

Do you experience anxiety without a clear reason?

yes

no

How do you cope with stress and emotions?

Rate your stress level (1–10)

Is your stress related to work or family?

Work

Family

Both

Other

Have you experienced any significant stressful or traumatic events?

Do you have memory problems?

yes

no

Do you experience brain fog or dizziness?

yes

no

Do you get cold easily?

yes

no

Are you prone to mouth ulcers (aphthae)?

yes

no

Have you noticed a white or yellow coating on your tongue?

yes

no

Do you experience bad breath?

yes

no

Do you have any root canal–treated teeth?

yes

no

Have you ever had a head or spine injury?

yes

no

Medical procedures or surgeries you have undergone

Describe your bowel movements

Are there any foods you cannot tolerate?

Do you often experience digestive issues? (belching, reflux, heartburn, bloating)

How do you feel after meals?

I gain energy

I feel tired

I feel drowsy

Other

Do you have haemorrhoids?

yes

no

How often do you take painkillers? Which ones?

Do you drink alcohol? How often? What type?

Do you smoke cigarettes?

yes

no

What beverages do you drink, and how much per day?

Additional Notes / Other Comments

Nature of Services Provided at Plasma-Med

I acknowledge that all treatments provided at Plasma-Med — including but not limited to nutritional support, natural therapies, IV vitamin infusions, hydrogen therapy, biorezonance, detox protocols, and complementary wellness therapies — are supportive in nature.

These services are intended to improve overall well-being, support recovery, strengthen the immune system, and enhance quality of life, but they are not medical cancer treatments.

Medical Supervision

I confirm that:

I remain under the care of my oncologist and/or medical specialist.

I will not stop, delay, or modify any medically prescribed oncology treatment without consulting my doctor.

I have disclosed accurate information regarding my diagnosis, treatments, medications, and supplements.

Scope of Responsibility

I understand and accept that:

Plasma-Med does not diagnose cancer or monitor cancer progression.
Plasma-Med does not offer medical treatment for cancer.
Therapies may support wellbeing but results vary for each individual.
Plasma-Med practitioners do not make decisions regarding oncology treatment protocols.
Complementary therapies are not intended to cure or treat cancer.

Patient Consent

I declare that:

I have received clear and understandable information about the supportive nature of Plasma-Med services.

I have had the opportunity to ask questions.

I understand the voluntary nature of these therapies.

I consent to receiving complementary/supportive treatments at Plasma-Med.

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Naturopathy Intake Form

Nature of Services Provided at Plasma-Med

Medical Supervision

Scope of Responsibility

Patient Consent