CASE HISTORY FORM



HEALTH QUESTIONNAIRE - INTAKE FORM

|PERSONAL DETAILS |DATE: / / |

|Surname: | |Given Name: | |

|Date of Birth: | |Preferred Name: | |

|Email: | |Address: | |

|Phone: | |Relationship status: | |

|Occupation: | |Children: | |

Health goal: (What would you like to get out of this consultation?)

Diagnosed medical conditions (and date of diagnoses):

Current health problems/symptoms:

Medical history (past treatments, operations and other relevant information):

|SYMPTOMS |

|Medication Name |Brand |Dosage |Duration |Related Condition |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|PAST MEDICATIONS |

|Medication Name |Brand |Dosage |Duration |Related Condition |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|CURRENT SUPPLEMENTS |

|Supplement Name |Brand |Dosage |Duration |Related Condition |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|CURRENT HEALTH |

|Height: |Weight: |

|Do you smoke? |Yes / No |

|How many per day? | |

|For how long? | |

|Are you or have you been on the birth control pill? |Yes / No |

|For how long? | |

|MEDICAL HISTORY |

|Mother’s medical history: | |

|Father’s medical history: | |

|Sibling’s medical history: | |

|Food/ environmental allergies | |

|Food intolerances/ sensitivities | |

|Dental amalgams/how many? | |

|DIGESTIVE HEALTH QUESTIONS |

|How do you feel after meals? |Erratic |Sluggish |Good |Balanced |Thirsty |

|Do you have a daily bowel movement? |Yes / No |

|How many? |< 1 / 1 / 2 / 3 / 4+ |

|Do you have constipation? |Yes / No |

|Do you have diarrhoea? |Yes / No |

|SLEEP QUESTIONS |

|Do you wake up in the night? |Yes / No |What time? |

|Average hours sleep per night? | |

|Do you get to sleep easily? |Yes / No |

|Do you feel rested when you wake up? |Yes / No |

|DIET DIARY |

|Breakfast: |Time: |

|Lunch: |Time: |

|Dinner: |Time: |

|Snacks: |Time: |

|What treats do you like: |

|DIET |

|For the following foods please list percentage in your diet: |

|Raw food |

|Do you drink alcohol? |Yes / No |If yes, what types? |How often? |

|Do you drink coffee? |Yes / No |How much? Cups/day |

|Do you drink tea? |Yes / No |How much? Cups/day |

|Are you on a diet? |Yes / No |If yes, since when? |

|Are you vegetarian? |Yes / No |If yes, since when? |

|Are you vegan? |Yes / No |If yes, since when? |

|APPOINTMENT BOOKING |

|When is the best time for a consultation? |

|Day: | |

|Time: | |

|Time zone: | |

|Please select the method you prefer and supply the relevant contact information |

|Zoom: | |

|Phone: | |

|Facetime: | |

|How did you hear about us? | |

By booking a consultation, you agree to pay a 50% deposit before the consultation date and the remaining 50% within 7 days after the consultation.

Consultation fees: Initial consultation $220 AUD

Follow-up consultation $90 AUD

Please send the completed Health Questionnaire Intake Form along with any recent pathology reports to: Bradgleech@[pic]

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