Make your Booking

As a new patient, please fill out all blocks below with your information to streamline your first appointment with us.

Preferred date and time of appointment (YYYY/MM/DD) *

Date

Time

Title

Name *

First

Last

Identity Number *

Date of birth (YYYY/MM/DD) *

Age

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Number

Email *

Marital Status

Gender

Occupation

Employer

Medical Aid Provider

Medical Aid Membership Number

Medical Aid Plan

Main Member of Medical Aid

Do you understand that the account remains your responsibility until fully paid and that full payment is required at your appointment. Should you wish to claim back from your Medical Aid, that will remain your responsibility.

Next of Kin Name *

Next of Kin Contact Number *

Next of Kin Relationship *

Do you have (or had in the last 7 days) any of the following symptoms…

Fever, chills, body ache, cough, sore throat, shortness of breath, runny nose, lost of taste or smell

Do you have a past history of covid 19?

If yes please provide the date or month you had covid 19

If yes do you have any new symptoms or disorders since you had covid 19?

I agree that I am providing accurate health information and that the information provided is true and correct.

Have you had any blood test done in the last year? If yes which lab did you go to eg. Lancet, Ampath, Pathcare vermaak ?

Date of last blood test

Date that you last checked your :

Blood glucose

Cholesterol

PAST MEDICAL HISTORY

Do you have/had any of the following disorders?

Diabetes
High cholesterol
Thyroid
High Blood Pressure
Cancer
Female disorders. Eg endometriosis, pcos, pms, fibroids,etc.
Skin disorder eg. psoriasis, dry/wet eczema
Leukaemia
Heart disease
Autoimmune
Pneumonia
Pulmonary embolism
Asthma
Male disorders
Emphysema
Stroke
Epilepsy/fits (seizures)
Eye disease
Aneamia Eg iron def, sick cell
Kidney/disease stones
Arthritis/Gout
Crohn's disease/ ulcerative colitis
Liver disease
Jaundice
Hepatitis
Stomach or peptic ulcers
Rheumatic fever
Tuberculosis
HIV/AIDS
Cognitive disorders eg. Depression, anxiety, bipolar, panic attacks, fears, anger, paranoia

Please list any disorders that any of your family members (biological mother, father, and grandparents) have/ had

Other medical conditions

Are you pregnant/ nursing *

Have you been to hospital or undergone any surgeries, if so when?

Current medication (Vitamins and supplements included as well as dosage)

Layout

Name of drug/supplent/vitamin(s)

Dose (include strength & number of pills per day) How long have you been taking this?

SOCIAL HISTORY

Do you drink alcohol?

Units per day/week

Do you smoke?

If yes, how long have you been smoking for?

Please include amount of cigarettes per day/week

Have you/do you engaged in drug/substance abuse?

If yes how long are you/have you been on these drugs

Please list drugs

Do you exercise?

How many Minutes per day?

how many times per week?

Type of exercises

Hours of sleep per day

Do you drink caffeinated coffee?

If yes how many cups per day

Do you drink pre-workouts?

If yes how many times per day

DIET

Please provide a brief description of what you eat:

Breakfast

Lunch

Supper

Snacks

Are there any foods that you dislike?

Please provide a brief description of your main complaint / Pain / area of concern?

ACKNOWLEDGEMENT

I, the undersigned in accordance with high standard patient care, consent Dr Ramsammy to provide the following, but not limited to…

Personal information collection, sharing of patient info to other healthcare providers/referral doctors, diagnostic physical examinations, finger prick tests (blood glucose/cholesterol), diagnostic treatment protocols (may include oral medication, injectables , acupressure, body work or essential oils, meditation), investigation of any blood lab tests and counseling.

The sale/dispensing of homeopathic medicines, supplements or other items required and in accordance with the prescription will be provided in relation to my health care needs.

I understand that Dr Ramsammys treatment focuses on the whole person. This means that she considers mental, emotional, physical, social and general factors that may be influencing your health.

I understand that Dr Prinita Ramsammy is a qualified homeopath who is registered with the Allied Health Professions Council of South Africa and the Board of Health care funders.

I understand that a homeopathic practitioner may diagnose and treat disease, illness and deficiency in the patient with homeopathic medicines.

I understand that homeopathic medicines are safe to use alongside conventional treatments and do not cause harmful side-effects. In some cases, a temporary aggravation of symptoms may occur as part of the natural healing process.

I understand that any information shared during the consultation is considered private and confidential and will not be disclosed without written permission, except where required by law or as described above for professional care or treatment.

ID Number

Date

Signature

Make your Booking

As a new patient, please fill out all blocks below with your information to streamline your first appointment with us.

Do you have (or had in the last 7 days) any of the following symptoms…

Date that you last checked your :

PAST MEDICAL HISTORY

Current medication (Vitamins and supplements included as well as dosage)

SOCIAL HISTORY

DIET

ACKNOWLEDGEMENT

Thank you for taking the time to complete this form

Begin Your healing journey from within...
Contact us

Call Today

La Como Fitness Club 25 Heron St, Parkhaven, Boksburg, 1465

Book an Appointment:

Make your Booking

As a new patient, please fill out all blocks below with your information to streamline your first appointment with us.

Do you have (or had in the last 7 days) any of the following symptoms…

Date that you last checked your :

PAST MEDICAL HISTORY

Current medication (Vitamins and supplements included as well as dosage)

SOCIAL HISTORY

DIET

ACKNOWLEDGEMENT

Thank you for taking the time to complete this form

Begin Your healing journey from within... Contact us

Call Today

La Como Fitness Club 25 Heron St, Parkhaven, Boksburg, 1465

Book an Appointment:

Begin Your healing journey from within...
Contact us