Health Form
Health Form & Vital Questionnaire
Email *
Title *
First Name *
Surname *
Date of Birth *
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/
DD
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Address  Unit/Street Number *
Address  Street Name *
Address  Suburb/Postcode *
Address  State *
Mobile Number *
Email *
What is your 'medical history' and diagnosis if any? *
What are your health concerns? (Describe in detail, including the severity of the symptoms.) *
What would you like to improve? *
Thinking about your main health concerns and current conditions, what therapies have you tried? What has worked and what hasn't? *
How is your current health situation impacting you? *
Why is now the right time to address these issues? *
What health and wellness goals are you seeking? *
What are your 3 month health goals? *
What are your 6 month health goals? *
Where do you want to be 12 months from now? *
How will you feel once you have achieved your health and wellness goals? What will life look like for you then? *
How is your sleep? How many hours do you sleep per night? *
Would you like to improve your sleep? *
How much water do you drink per day? *
Do you drink coffee/caffeinated products? If so how many per day? *
Do you consume alcohol? If so please list how often and the quantities? *
Do you smoke *
Do you take medications? If so please list them *
Are you currently under the care of a physician? If yes, please provide details  
 *
Do you take nutritional supplements including vitamins & minerals? If so please list them including the dosages *
Do you have any food allergies or intolerances? If so please list them *
What is your height and weight? *
What is you Blood Type?
Do you  eat organic or conventional produce? *
How many vegetables do you eat per day? *
How many fruits do you eat per day? *
How frequent are your bowel movements? *
Do you consume dairy, gluten and refined sugars? If so please list which ones and how often *
How many times a day/week do you consume animal products? Please list amounts accordingly *
Describe your relationship with food *
Do you use toxic personal care products including cosmetics and household products? If so please list them *
*Please note: All important information is collated to help me get a complete picture of your current health status, such as medications, supplements, allergies, recent medical diagnoses, or a summary of test results from your healthcare practitioner. (Please note that this information is only a guide and overview of where you are at, and any changes, adaptations, or other medical questions should be discussed with your healthcare provider.) 

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