Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.I understand further details will be taken at the appointment *YesNoDateName *FirstLastGenderMaleFemaleOtherEmail *Age (not full date of birth)SuburbPhone number *OccupationEmergency contact name and relationship to youEmergency contact phone numberPlease select *I am the clientI am the guardian of the clientI am the carer of the clientWhat are the main reasons for wanting to see me?Previous treatments or consultationsYesNoHave you seen someone previously regarding your health issues? This includes any complementary therapists, naturopaths, doctors or specialists.Allergies *(to any foods, medications, bites, stings) Medical History *Please list any conditions or surgeries you have had, or any other relevant informationFamily Medical HistoryPlease specify any medical conditions of blood-related family members, if known, and if possibly relevant. (eg mother, father, siblings, grandparents, children)Medications and supplements – Please include brand and dosage.Please detail any prescribed, self-prescribed, birth control, pain relievers, other over-the-counter products.Do you have any test results (eg bloods) to send to me?YesNoBeen done – awaiting resultsSleep issues – please mark all that apply to youCan’t get to sleepCan’t stay asleepWake up still tiredSnoring, sleep apnoeaLeg cramps, often at nightRestless sleeperWaking more than once to urinateRespiratory health – please mark all that apply to youHayfever, respiratory allergiesAsthmaFrequent colds or other respiratory illnessesShortness of breathSinus problems (including infections)Diagnosed lung problems (eg COPD)Mental and emotional healthAnxietyFeel sadIrritable, intolerant of othersPanic attacksLack motivationGut, digestion, elimination – please mark all that apply to youConstipationDiarrhoeaBloatingWindHeartburn/refluxCrave sugarAfternoon slump / tirednessFrequent urinationPain or difficulty urinatingPain or difficulty passing stoolAches, pains and other physical issuesHeadaches, migrainesCold soresCold hands and/or feetHot hands and/or feetCan’t lose weightCan’t gain weightVaricose or spider veinsMuscle or ligament issuesSkin problems (eg eczema, dermatitis)Get sick oftenArthritis (eg osteoarthritis, rheumatoid)For the ladiesMoody or weepy around periodIrregular periodsVery heavy periodsVery light periodsCramping around periodPregnantPeri-menopausal (or suspected)Menopausal (no period for 12 months)Vaginal drynessThrushHot flushes or night sweatsRecurrent urinary tract infectionsEndometriosis or PCOSFor the gentsErectile dysfunctionProstate IssuesUrination – too often, difficult to startSmoking or drugsYes I smokeI never smokedPreviously smoked, but quitI am on prescription medicationI use non-prescribed (over the counter) medicationsI use illicit drugsDrinksAlcoholWaterCoffee / teaHerbal teaFruit juices / smoothiesSoft drinksMilk or flavoured milk drinksDrinks you typically haveDiet informationOmnivore – I eat both meat and plant foodsVegetarian or veganCarnivore, ketogenic, paleoMedically prescribed dietOver 50% of my food is refined and processedLow carb, high fatI have food intolerances that affect my intakeWeight managementHigh sugar intakeDaily food intake On a typical day, what sort of foods would you eat? (Please note whether breakfast, lunch, dinner, or snacks)Any other information you would like to share before the appointment?Submit
