New Patient Form – Le Grange Diet Clinic

Are you a NEW PATIENT? Are you ready to take control of your nutrition?

Complete the New Patient Form, and we will get in touch with you to help you master your journey

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Patient Surname / Pasient Van *

Patient Name / Pasient Naam *

Patient Contact Number (Work) / Werks telefoon nommer

Patient Contact Number (Home) / Huis foon nommer

Patient Contact Number (Mobile) / Selfoon Nommer *

Patient E-mail Address / Pasient E-pos Adres *

Patient ID Number / Pasient ID Nommer *

Patient Address / Pasient Adres *

Please complete your address, including your town and code

Patient Occupation / Pasient Beroep *

Patient Allergies / Pasient Allergie *

Patient Medication / Pasient Medikasie *

Please list all the medication that you are currently taking daily / Lys asb alle medikasie wat u tans gebruik daagliks

Patient Height / Pasient Lengte *

Patient Weight / Pasient Gewig *

Patient Goal Weight / Pasient Doel Gewig *

Patient Blood Pressure / Pasient Bloed Druk

Will be taken at the clinic / Sal by die kliniek geneem word

Date / Datum *

Bottles / Bottels

At Clinic / By Kliniek

Do you exercise regularly / Oefen u gereeld? *

• Yes / Ja
• No / Nee

Are you a rehabilitated alcoholic / Is u 'n gerehabiliteerde alkoholis? *

• Yes / Ja
• No / Nee

Do you have high cholesterol / Het u verhoogte cholesterol? *

• Yes / Ja
• No / Nee

Do you suffer from Thyroid issues / Lei u aan Skildklier probleme? *

• Yes / Ja
• No / Nee

Do you suffer from Diabetes / Lei u aan Diabetes (Suikersiekte)? *

• Yes / Ja
• No / Nee

Do you have hypertension / Lei u aan verhoogte bloed druk? *

• Yes / Ja
• No / Nee

Do you/did you suffer from depression / Het u tans of voorheen aan depressie gelei? *

• Yes / Ja
• No / Nee

Do you Smoke / Rook u? *

• Yes / Ja
• No / Nee

Bottles / Adres

Do you breastfeed / Borsvoed u? *

• Yes / Ja
• No / Nee

Submit