Date of Birth:
Reason(s) for consultation:
Current treatment including medication(s) and natural supplementation:
Do you have any allergies? If so, please state:
Please tick any symptoms you experience more than once per month:AllergiesAsthmaBack/neck painCold hands/feetConstipationDiarrhoeaDizzinessFaintingFatigue/lethargyFrequent urinationHeadachesIndigestion/refluxJoint painMood swingsSciaticaSkin problemsSwollen/painful glandsOther
Female:Absent mensesHot flushesPainful mensesPMS
Have you had any illness, operations, or been hospitalised in the last five years? If so, please describe:
Have you had, or do you have any of the following diseases or problems? AlcoholismArthritisAsthma/respiratory problemsBlood disordersCancerCardiovascular disease/symptomsDiabetesEpilepsyHayfever/sinusHepatitis/liver problemsHIV/AIDSHormonal problemsInflammatory bowel disease (IBD)Kidney/bladder problemsMental disordersRoot canal therapySkin disordersStomach ulcersThyroid diseaseOther
Do you belong to a private health insurance fund?YesNo
Which health fund are you with?
What do you generally eat for breakfast?
What do you generally eat for lunch?
What do you generally eat for dinner?
Glasses of water consumed per day:
Cups of coffee/tea consumed per day:
Glasses of alcohol consumed per day:
Cans of soft drink consumed per day:
Amount of chocolate consumed per day:
Number of cigarettes smoked per day:
Recreational drug use:
On a scale of 1-10 how would you rate your diet?(1 = Poor, 10 = Very healthy)12345678910
On a scale of 1-10 how would you rate your stress level?(1 = Not stressed at all, 10 = Very stressed)12345678910
What do you think 'triggers' your stress?
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