Patient Sign Up Form

Thanks for your interest in the Budwig Center. In order for us to best assist you with your enquiry, please submit the form below. We look forward to hearing from you.

Contact Details

Please provide current contact details

Name

Telephone

Email Address

Address






Personal Information

Occupation

Your Gender

FemaleMalePrefer not to say

ID Number (e.g. passport or driving licence)

Your Diet

Which of the following do you consume on a weekly basis?

Commercial Ice-Cream (white refined sugar)Store-Bought Pastries (white refined sugar)Soft/Fizzy Drinks/Soda (white refined sugar)Boxed Cereals (white refined sugar)Fructose (white refined sugar)Chocolate Bars (white refined sugar)Corn Syrup (white refined sugar)Aspartame (artificial sweeteners)Equal® (artificial sweeteners)NutraSweet® (artificial sweeteners)Nutrinova® (artificial sweeteners)Saccharin (artificial sweeteners)Splenda® (artificial sweeteners)Twinsweet ® (artificial sweeteners)Sweet 'N Low® (artificial sweeteners)Fried FoodsFried ChickenFrench FriesChips (Crisps)DoughnutsVegetable Cooking OilsCheeseMilkYoghurtLobsterClamsShrimpPrawnsSquidOctopusHamBaconHot DogsSausagesCold Cuts and Prepared MeatsWhite Meats (Fish & Chicken)Red Meats (Beef, Lamb, etc)

Your Health

Please provide an overview of the current state of your health.

What type of illness or health issue(s) are you experiencing?

If you have cancer, there is it located (in the case of metastasis, please indicate primary cancer)

Have you had, or are you currently receiving chemotherapy and/or radiation treatment?

YesNon/a

When was your illness diagnosed?

Have you had any surgery relating to this problem?

YesNon/a

Is there any relevant medical history you can share? (e.g. surgeries, hospitalization, illness, etc)

Are you experiencing any of the following (please check all that apply)?

Allergies or IntolerancesPainAscites or Edema (fluid retention)Metal Fillings (amalgam, nickel, etc)Hearing ProblemsDizzinessVertigoTinnitusHeadachesNeck/Shoulder/Back Pain or TensionImplants (Breast, Lips, Eyebrows)Excessive Weight LossInsomniaNightmaresUrinate more than twice a nightCold FeetHigh Blood PressureLow Blood PressureIndigestion / Bloating / HeartburnUrinary InfectionsConstipationHaemorrhoidsShort-TemperednessIrritabilityNervousnessAnxietyDepression or other Mental IllnessProblems eating or swallowingConfined to wheelchair or bedTrouble climbing one flight of stairsMy job requires a lot of standingMy job requires a lot of sitting

In the last 5 years, have you experienced any emotional shock?

If you suffer pain, where is it located?

On a scale of 1 to 10, how bad is the pain (1 being mild, 10 being severe)

12345678910

If you suffer ascites or edema (fluid retention), where is it located?

If you have metal fillings, how many?

123456789More than 10

If you are a smoker, how many cigarettes do you smoke per day?

Less than 55 to 1010 - 2020 - 30More than 30

If you have tattoos, how many?

123456789More than 10

Is there anything else you would like to add that you think we should be aware of?

Please list all pharmaceutical medicine you are currently using

Your Declaration

By ticking this box, you agree to our terms of service and privacy policy regarding how we use your personal data.

Yes - I agree to the Budwig Center Terms of Service and Privacy Policy