Please fill in all of the information below honestly and to the best of your ability. This information will be kept strictly confidential as per the bylaws of the College of Naturopathic Physicians of BC (CNPBC). Your personal information is collected for the purpose of providing health care and for administrative purposes. It will not be disclosed for other purposes without your consent other than for reasons stated in the bylaws of the CNPBC. A copy of these bylaws may be found at the CNPBC website (www.cnpbc.bc.ca) or we will print a copy of the relevant section for you at your request.When you get to the bottom of each page, click NEXT until you reach the end where leave your signature. Thank you!
0 = Do not consume or use
1 = Consume or use 2 to 3 times monthly
2 = Consume or use weekly
3 = Consume or use daily
0 = never
1 = occasionally
2 = regularly
3 = often
0 = No symptoms
1 = Minor/mild symptoms, occurs rarely (monthly)
2 = Moderate symptoms, occurs occasionally (weekly)
3 = Severe symptom, occurs frequently (daily)