Client details and history
Please complete questions with as much detail as possible
Name *
Enter your full name
Your answer
Address *
Street number and name
Your answer
City *
Your answer
State *
Postcode *
Your answer
Home phone number *
Your answer
Mobile phone number *
Your answer
Work phone number
Your answer
Email *
Your answer
Referred by *
Friend/family, website, Google, advertisement, Facebook
Your answer
Age *
Your answer
Date of Birth (format month/day/year) *
MM
/
DD
/
YYYY
Gender *
Height *
Your answer
Weight *
Your answer
Family/living situation *
Who do you live with?
Your answer
Children *
Do you have children? If yes, list their names and ages
Your answer
Occupation *
Your answer
Exercise and recreation *
Please list any exercise or recreational activities that you undertake
Your answer
How much physical activity do you do? *
Daily average over 1 week
No physical activity
Marathon runner or equivalent
Have you lived or travelled outside of Australia? If so, when? *
Your answer
Have you or your family recently experienced any major life changes? *
Please explain
Your answer
Have you or your family experienced any major life changes in the past? *
Please explain including rough time frame
Your answer
Have you experienced any major losses in your life? If so, please comment *
Your answer
Medications *
List of all current medications with doses and frequency
Your answer
Do you take any vitamins, minerals, other supplements *
Please list
Your answer
Have you had any surgery? *
Please list including dates
Your answer
Past medical history *
Required
Family History
Mom
Dad
Brother
Sister
Grandparent
Child
Other relative
Cardiovascular disease (heart disease, stroke)
Diabetes
High blood pressure
Cancer
Other
Tobacco use history
Currently high use
Current low-med use
Former use more than 6mo ago
No current or former use
Tobacco use
Alcohol use
Drug use 
Diet
Any dietary restrictions? Adherence to a specific diet? Dietary concerns?
Your answer
What are your main health concerns? *
Your answer
When did you first experience these concerns? *
Your answer
Have you tried any other treatments for these concerns? Please comment
Medical doctors, natural health practitioners, medication, supplements, etc
Your answer
Have you experienced success with these approaches?
Your answer
What other health professionals are you currently seeing?
Please list name and type of practitioner
Your answer
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