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Blood Type (If Known)
What surgeries have you had?
Are you currently taking any medications?
If Yes, please list current medications:
Energy Level (1 low, 10 high)?
How often are you on antibiotics?
What brought you to Health Matters?
Please SIGN and DATE here to acknowledge you have read the disclaimer below:
My services neither diagnose nor prescribe for disease conditions. All clients are encouraged to seek competent medical help when those services are deemed necessary. The client accepts total responsibility for his/her own health care and maintenance. The client agrees to indemnify and hold Dymphna Baudoin harmless from any and all health consequences arising from client’s personal decisions.
Dymphna Baudoin is not nor does she hold herself out to be a licensed healthcare practitioner in any jurisdiction within the United States of America. The client is solely responsible for making his or her own health and wellness decisions, and has in no way been unduly influenced into a course of action by Dymphna Baudoin regarding their personal health and wellness circumstances.
Any and all information provided by Dymphna Baudoin is for educational and informational purposes only. No analysis, information or recommendation made by Dymphna Baudoin is to be construed in any way to be the rendering of medical advice, diagnosis, treatment, prevention or cure of any disease. Many natural products are widely used and accepted in many parts of the world. Statements about products that may be discussed by Dymphna Baudoin have not been evaluated by the Food and Drug Administration of the United States of America. It is expressly understood the systems, products and education offered by Dymphna Baudoin are not intended to diagnose, treat, cure, prevent or mitigate any disease.
I acknowledge that alcohol may be used as a carrier of additive in homeopathies recommended. This acknowledgement shall survive in perpetuity with the original to be placed in the Client’s permanent, confidential record in the office of Dymphna Baudoin or other such location as Dymphna Baudoin may deem appropriate. Your assessment, both full and partial, is used to gather health information and not to establish a medical diagnosis. We hope that your experience with our office has been very beneficial to you and your overall health.
I have read and understand the above statement fully
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