Adults Intake Form
We aim to meet all of our client’s health and wellness needs with the highest level of care. Your health journey is an ongoing commitment and we are 100% on board with you! We have a proven Four Step system that involves regular appointments, 2-4 weeks apart, to get you started.

We will assess your health and design a treatment program that ensures you reach your goals. Together we will put together a structured and detailed action plan outlining your short term and long term goals.

Overview:
• Case Review Consultation – involves a full case history, referrals to appropriate practitioners & recommendations for any pathology. You will receive a clear, written treatment plan that addresses your immediate concerns.

• Testing appointment – approximately 1-2 weeks later, point of care testing occurs with weight, body measurements, zinc test, pH test, tongue analysis, full dietary analysis and specific questionnaires. Bio Impedance Analysis, a scientifically validated test that assesses the health of your cells and body composition is included.

• Report of Findings – involves a full assessment of your pathology results, functional medicine test results, dietary changes and then implementation of your full treatment protocol which takes into account underlying causes. In this report of findings you will receive a clear, written treatment plan that addresses both your short and long term goals.

• Follow up visits - we monitor your response to your treatment plan, tweak and adjust treatment depending on progress, test results or your responsiveness, order further tests and be your committed partner by offering accountability for your actions.

Both before and after your appointments, we spend time researching your health, reviewing your goals and finding the best options for you. This also involves communicating with your other health care providers, presenting your case to our Studio You practitioner board or writing reports. We do this because we practice the highest level of best practice possible and we take your health seriously.

Please fill out this questionnaire and then email (info@studio-you.com.au) or fax (9216 7609) any blood test or pathology results you have had done in the past 12 months.

Email address *
Your answer
Full Name
Your answer
Date of Birth
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YYYY
Who referred you to Studio You?
Your answer
Postal Address
Your answer
Mobile phone number
Your answer
Current Height & Weight
Your answer
Occupation
Your answer
GP
Your answer
Specialist
Your answer
Please list your main concerns and reasons for this appointment
Your answer
Have you had any investigations/ tests/ operations / hospitalisations. Please list
Your answer
Current medications, herbal or nutritional supplements
Your answer
Medical history - please list all you can think of
Your answer
Do you smoke? If so how much?
Your answer
Do you drink alcohol? If so how much?
Your answer
Do you take recreational drugs? If so how much?
Your answer
Do you consume caffeine (coffee, energy drinks, black tea, chocolate)? If so how much?
Your answer
Exercise - type, duration and frequency
Your answer
Daily Water intake
Your answer
Allergies
Your answer
Foods you avoid and why
Your answer
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