Full Name (required)
Street Address (required)
Suburb (required)
Postcode (required)
Postal Address (if different to above)
Email Address (required)
Home Phone
Work Phone
Mobile Phone
Fax Number
D.O.B.
Age
Weight (kg)
Height (cm)
Sex
MaleFemale
Marital Status
Partner's Name
No of children
Health Fund
Occupation
Years at this occupation
Basic description of job duties: (heavy lifting, typing, etc.)
Full Name
How Did You find out about Our Clinic
Referral from family member/ friend (please provide the name below)Referral from Doctor or other practitioner (please provide the name below)Advertising / Mail OutSignWebsiteHealth Talk / SeminarNewsletter
Other:
Referrer's name:
AsthmaCancerDiabetesIDNon IDEpilepsy / SeizuresHepatitisHIV / AIDSHeart DiseaseHigh Blood PressureLow Blood PressureLeukaemiaMultiple SclerosisPoliomyelitisTuberculosisPacemakerJoint ReplacementSurgical ImplantsCar AccidentWorked With Toxic SubstancesRecent Vaccination
Drug Allergies
Other Allergies
Other Conditions
Have you been hospitalised for any other reason?
YesNo
Have you been on an overseas trip in the past two years?
Major injuries or accidents (include dates)
Surgical operations (include dates)
Current medication and Supplements (include reasons for taking and duration)
Family History
Life Style
SmokeDrink Alcohol - please provide details belowDrugs - please provide details belowSpecial Diet - please provide details belowExercise - please provide details below, e.g. how many times per week?
Details:
Recent Prostate ExaminationRecent Testicle ExaminationProblem Getting an ErectionProblem Maintaining ErectionPremature EjaculationDifficulty Urinating
Pregnant - if so, enter weeks below
Weeks Pregnant
Number of Pregnancies
Number of Past Terminations
Contraception
Age at first period
Last Period
My Period is usually: HeavyLightPainful
With my Period I also get: PMSDischargeClotting
I am Menopausal: YesNo
Birth Order: (e.g. ... of ...)
APGAR: (... /9)
IVF YesNo
Term of Pregnancy (weeks)
Delivery
Complications
Feed Straight YesNo
Humidi-Crib YesNo
If yes, how many days?
Born with hair YesNo
Teething
Toilet Trained YesNo
Flat Feet (Shoes Off) YesNo
Vaccinations Hepatitis BDiphtheriaWhooping CoughHib (Flu)MMRTetanusCervical CancerVit KGiven Panadol (for fever)
Reaction for Vaccination:
Total Courses of Antibiotics in Lifetime:
Sweats Easily/For No Reason
Hours Sleep/Night
Hours TV, etc. /Day
Sport
No. Games, Training/wk
No. Stools/Day
FirmSoftSmellFood
No. Urination/Day
Appetite
BigSmallPicky
What is your main problem or reason for seeking treatment?
On a scale of 1 to 10 (1 = no problem, 10 = worst possible), where is your problem?
Right now?
When it is at it's worst?
Where do you want it?
If not 1, why not?
What have you tried already to fix this problem?
Why did you stop? MoneyTimeOther commitmentsDidn't work
Other reasons:
What specifically do you want from your treatment?
How will you know when you've achieved the result you're after?
When you've achieved that, how will it make you feel?
How serious are you about fixing this problem? (1 = not serious, 10 = completely)
If you scored yourself less than 7, why is that?
Treatment requires a commitment of time, energy and finances. Is someone else involved in making financial decisions about your health? Who:
Have you discussed and agreed your treatment is within your budget? YesNo
What factors could possibly stop you from completing a recommended treatment plan?
What do you think will happen to you if you don't take action now to fix this problem?
If I can show you a simple, step-by-step way to improve your health and achieve your desired results, how soon do you want to get started? Right awayIn a few weeksNo real rushI'm just curious for now
Imagine it's 6 months in the future. You've fixed this problem, and achieved the results you want with your health. Looking back, what would you say to yourself about your decision to have this treatment now?
Δ