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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