Waiver. 2 Medical Waiver and Release of LiabilityChandan Makhijani is not responsible for negligence, negligent use or health-related consequences regarding the use of naturopathic nutritionist advice. Chandan Makhijani cannot be held responsible for lack of education regarding the use of naturopathic nutrition. We encourage you to research the use of naturopathic nutrition and how it can affect your individual health. By signing the line below you agree not to hold Chandan Makhijani responsible for any issues that may arise from the use of naturopathic nutrition and the advice of Chandan Makhijani. Please enable JavaScript in your browser to complete this form.Signature *Print Full Name *Date / TimeDateTimeAssessment FormNew Patient Information and Case Taking Form Name *FirstLastAddressAddress Line 1CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhoneDate of BirthHeight and WeightMedical InformationReason for consultation: Current diagnosis, if you have one:Have you taken medications or treatments concerning your current issue or diagnosis? If so please state medications and how long was it taken for Explain the treatment taken if any How would you describe your overall health? Do you have any issues with sleep?YesNoDo you have any issues with digestion? YesNoDo you have any issues with mood? If so please detail them here: Have you had any accidents, injuries or surgeries in the past 10 years? If so please detail here:LifestyleDo you exercise: YesNoIf yes , how often? Which type of exercise? Other physical activities? Do you smoke Tobacco? YesNoIf yes, please state how many a day or a week: Do you consume alcohol?YesNoIf yes, please specify how frequently: Do you consume Cannabis? YesNoIf yes, please specify how frequently:Any other Drugs? YesNoIf yes, please specify:How often are you exposed to sunlight? Which type of Work do you do? From a scale of 1-10 (10 being the most) how stressful is your work? 12345678910How much water would you say you consume a day? Do you take any supplements? YesNoIf yes please list them here Do you consume coffee or energy drinks? YesNoIf yes please specify Which types of cooking oil do you consume? List them here Which type of salt do you consume? How often do you eat fast food? How often do you eat home cooked food? What is your average breakfast? What is your average Lunch? What is your average Dinner? What are you average snacks? What is your average beverage? Additional informationDo you have any tooth fillings? YesNoIf yes how many? Do you have any allergies? When was the last time you had a fever? Flu? NameSubmit