Health Questionnaire

Name*

First Last

Email*

Enter Email Confirm Email

Date of Birth*

Address*

Street Address Address Line 2 Suburb ZIP / Postal Code Country

Mobile*

Home Phone

Work Phone

Occupation*

Where did you hear about us?

Google/Internet Search
Event/Advertising
GP/Healthcare provider
Family Friend
Other

Please Specify:

Emergency Contact

Name*

First Last

Relationship*

Contact Number*

Main reason for your visit*

Medical History

Have you had any medical exam test or x-rays in the last 5 years?*

Yes
No

Please Specify:

Have you ever had any surgical operations?*

Yes
No

Please Specify:

Are you currently undergoing medical treatment?*

Yes
No

Please Specify:

Have you every had Radiation or Chemotherapy?*

Yes
No

Please Specify:

Are you allergic to any foods or environmental substances?*

Yes
No

Please Specify:

Are you currently taking any prescribed medication?*

Yes
No

Please Specify

Name of Product	Dosage (Per Day)	Start Date

Are you currently taking any natural supplements?*

Yes
No

Please Specify

Brand	Name of Product	Dosage (Per Day)	Start Date

Do you, or have you ever used recreational drugs?*

Yes
No

Please Specify

Vaccinations

Have you ever been vaccinated?*

Yes
No

Were you fully or partially vaccinated?*

Full
Partial

Do you have regular flu shots?*

Yes
No

Have you experienced any adverse reactions to vaccines?*

Yes
No

Occupations

Please list your current and former occupations and pastimes:

Occupation(s)*

Pastime(s)

Do you, or have you ever smoked cigarettes/cigars?*

Yes
No

Do you, or have you ever drunk alcohol?*

Yes
No

Have you ever worked with chemicals including garden sprays?*

Yes
No

Please specify

Do you have any of the following?

Please Enter any other conditions you have/have had in the past.

Is there a family history of any conditions?*

Yes
No

Mother*

Mothers Father*

Mothers Mother*

Father*

Fathers Father*

Fathers Mother*

Siblings:*

Other:

Dental & Oral Health

Have you ever had dental or oral health issues?*

Yes
No

Please Specify:

Do you grind/clench your teeth?*

Yes
No

Female Only

Are you currently pregnant?

Yes
No

Have you been pregnant before?

Yes
No

Have you had abnormal periods?

Yes
No

Please Specify:

Have you had a miscarriage/abortion in the past?

Yes
No

At what age did you first menstruate?

Please enter a number from 1 to 100.

Have you experienced any menstrual problems during puberty?

Yes
No

Are you currently on contraceptives?

Yes
No

Please Specify:

Have you ever been on contraceptives?

Yes
No

Please Specify:

Have you ever been on Hormone Replacement Therapy (HRT)?

Yes
No

Please Specify:

Have you ever had symptoms from contraceptives or HRT?

Yes
No

Please Specify:

Male

Have you ever had a vasectomy?

Yes
No

Have you ever had any prostate issues?

Yes
No

Have you ever experienced erectile dysfunction?

Yes
No

Stools

How often do you pass stool?*

times per*

Do you have diarrhoea often?*

Yes
No

Do you have, or have you had, piles or haemorrhoids?*

Yes
No

Do certain foods affect your bowel motions?*

Yes
No

Do you get anal itch?*

Yes
No

Do you get rectal bleeding?*

Yes
No

have you had recent unexplained weight change?*

Yes
No

What colour is your stool normally?*

Brown/Light Brown
Light Yellow
Green
White/Clay
Black

Urine

Do you experience difficulty urinating?*

Yes
No

Do you experience problems with frequency/urgency of urinating?*

Yes
No

What colour is your urine normally?*

Clear/Pale Yellow
Yellow
Dark Yellow
Pink/Red
Brown/Orange
Foaming/Fizzing

Weight & Metabolism

Do you have any problems maintaining your ideal weight?*

Yes
No

Do you feel cold unduly?*

Yes
No

How would you rate your appetite*

Exercise

Please note down your exercise regime below

Type of Exercise	Duration	Frequency (Per Week)

Diet

How much water do you drink daily?*

*

Do you drink tea/coffee/fruit juices etc...?*

Yes
No

Please Specify:

Do you drink tap water?*

Yes
No

Please list any foods you may have intolerance to:

Please list any foods you actively avoid:

Please list any foods you crave:

What type of foods do you typically eat from day to day?

What foods do you eat for Breakfast?*

Weekday	Weekend

What foods do you eat for Lunch?*

Weekday	Weekend

What foods do you eat for Dinner?*

Weekday	Weekend

What foods do you eat for Snacks?

Weekday	Weekend

Thank you for your time.

Please note that all information provided will be strictly confidential and will not be disclosed to anyone without your permission.

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