Questionnaire

  • Declaration

    I fully understand the explanation of the treatment I am about to receive. I accept that the practitioners are not medical doctors and if I have any symptoms of a medical nature I have already consulted my doctor before deciding to undergo any alternative therapy. This is solely my decision to go ahead with the treatments recommended and does not replace any medical advice already given by my doctor. I understand that Beechcroft Retreats is a holistic establishment and the practitioners are naturopathic consultant and not medical doctor. We do not treat/cure cancer, all prescribed Medication should be taken as advised and is your responsibility. No personal care will be provided, if required this must be arranged by the clients carer/family. No phones will be allowed to be used, in an emergency we can arrange calls on request. All information that I will provide is accurate and to the best of my knowledge.
  • Personal Details

  • Contact details

  • Medical details

  • Do you currently have or ever had any or the following medical conditions?

  • (Approximate)
  • (Approximate)
    (1 to 2 times per day)
  • Tick any of the below that you suffer from

  • Dietary

    Please describe briefly what you eat for