Before we meet

Your client case form

Completed ahead of your initial consultation, this confidential form gathers your personal details, medications, supplements and family health picture — so our time together is spent on you, not paperwork. The more detail you can give, the more accurately personalised your plan will be.

Everything else — your health story, systems review and personalised plan — is explored together with Barbara during the consultation itself. Not ready for this step? Request a free discovery call instead.

Confidential · Reviewed only by Barbara · Stored in line with GDPR

About you

First name * Last name *

Email * Telephone number/s

Date of birth * Gender

Address

Marital status Children

Occupation Referred by

Height Weight

Your general practitioner

GP name GP telephone number

GP address / practice

Do we have permission to contact your GP if it becomes necessary to do so?

Yes No

Prescription medications — past and present

Include anything you take now or have taken in the past that feels relevant. Leave blank if none.

Name of medication Reason for taking / side effects Dose Taken since Frequency of intake

Other notes (including hormonal contraceptive use)

Natural therapies & supplements

Please include all your current supplements, and any herbal or natural remedies (including topical).

Natural therapy / supplement Reason for taking Dose Taken since Frequency of intake Prescribed or self-prescribed?

Family medical history

Please include information on any health conditions in your family such as cancer, diabetes and autoimmune conditions.

Mother Father

Grandmother (maternal) Grandmother (paternal)

Grandfather (maternal) Grandfather (paternal)

Brother(s) Sister(s)

Recent tests & diagnosed conditions

Any recent test results (in the last 6 months) or diagnosed conditions I consent to Your Panacea storing the information above securely and using it to prepare for my consultation. All information is confidential and handled in line with GDPR. *