Information collection I am required by law and my professional association to collect full and complete information. To protect your privacy, minimal specific identifying details only are included on this form, but will be required to be completed when you attend the appointment.Submitting this form Once the form has been successfully completed, you will get a confirmation message on the screen. If this doesn't appear, go back and check if you have missed completing one of the required fields or tick-boxes (look for the red *). I look forward to helping you soon.I understand further details will be required at the time of the appointment. I give consent to treatment, or I am authorised as guardian to consent to treatment. I have supplied information to the best of my knowledge and understand that information supplied will affect any treatment or advice given.yesnoPersonal information (of client)Name *Gender *MaleFemaleOtherEmail *Age *Suburb *Phone *Occupation *Emergency contact name *Relationship to you Emergency contact phone number *Please select *This is to indicate who has completed the form.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 consultations Have you ever seen anyone previously in regard to your health issues? This includes complementary therapists, naturopaths, doctors or specialists.yesnoAllergies (to any foods, medications, bites or stings). *Medical History *Please list any conditions or surgeries you have had, or other relevant information hereFamily Medical History *Please list medical conditions of blood-related family members if known.Please list any medications or supplements you are taking, including brand, dosage you are taking, and why you are taking it. *Please include any prescribed, self-prescribed, over-the-counter items, birth control, pain relievers, etc.Do you have any test results (blood tests, etc) to bring in or send me? YesNoBeen done, awaiting resultsPlease mark any boxes that are relevant to you Sleep issues Please mark any that apply to youCan't get to sleepCan't stay asleepWake up still tiredRestless sleeperSnoring, sleep apnoeaHave to get up more than once at night to urinateVery light sleeper - can't get enough deep sleepGet leg cramps during the nightRespiratory health Please mark any that apply to youHayfeverShortness of breathAsthmaSinus problems (including sinus infections)Allergies (Hay fever)Frequent coldsDiagnosed lung problems (eg COPD)Diagnosed lung problems (eg COPD)Gut, digestion, elimination Please mark any that apply to youConstipationDiarrhoeaBloatingWindHeartburn / refluxCrave sugarAfternoon slump / tirednessFrequent urinationPain or difficulty with urinationPain or difficulty with passing stoolAches, pains and other physical issues Please mark any that apply to youHeadaches, migrainesLeg crampsSkin problemsAcneCold soresCold hands and/or feetHot hands and/or feetGet sick oftenVaricose or spider veinsArthritis (eg osteoarthritis, rheumatoid arthritis)General joint achesCan't lose weightCan't gain weightFor the ladies Please mark any that are relevantMoody around periodCramping before or during periodIrregular periodsVery heavy periodsVery light periodsVery light periodsMenopausal (not had a period for 12 months)Peri-menopausal (or suspected)Hot flushesNight sweatsVaginal drynessRecurrent cystitis (urinary tract infections)ThrushEndometriosisPCOS (polycystic ovaries)PregnantFor the gents Please mark any that apply to youErectile dysfunctionProstate issuesUrination issues - too often, difficult to startHave to get up more than once at night to urinateFood, exercise and habitsFood and exercise Smoking or drugs No judgement - I just need accurate informationNeverSometimesYesPreviously, but quit over 5 years agoQuit smoking within the last 5 yearsI am on prescription drugs / medicationsI use non-prescribed (over the counter) or illegal drugsDrinks Types of drinks you have on a typical dayCoffee / teaHerbal teaFruit juice, smoothiesAlcoholMilk or flavoured milk drinksWaterOtherExercise How often per week and what type of exerciseDiet information Omnivore - I eat meats and plant foodsVegetarianVeganCarnivoreKetogenic, paleo, etcMedically prescribedover 50% of my food is refined and processedLow carb, high fatI have food intolerances that affect my intakeWeight managementHigh sugar intakeOtherDaily 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 give me before the appointment? Thank you for taking the time to complete this form. I look forward to seeing you soon. VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
