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) *
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
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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
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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 *
Family History
Other relative
Cardiovascular disease (heart disease, stroke)
High blood pressure
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 
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
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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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