Pre-Consultation Questionnaire (PCQ)

DH-NATURAL MEDICINE CLINIC – CONFIDENTIAL CLIENT RECORD

Personal Details

    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.)

    Paediatric Patient Details

    Full Name

    D.O.B.

    Age

    Weight (kg)

    Height (cm)

    Sex
    MaleFemale

    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:

    MEDICAL HISTORY

    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?
    YesNo

    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:

    Males Only

    Recent Prostate ExaminationRecent Testicle ExaminationProblem Getting an ErectionProblem Maintaining ErectionPremature EjaculationDifficulty Urinating

    Females Only

    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

    CHILDREN ONLY

    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?

    Terms, Conditions, Disclaimer and Release
    • I understand and accept that payment for my treatment is required at the time of service.
    • I have reviewed the information on this questionnaire and it is accurate to the best of my ability. I understand that this information will be used to help determine an appropriate course of treatment.
    • All information gathered in this and subsequent consultations will remain strictly confidential.
    • There may be a material risk associated with this and subsequent consultations and formally consent to all physical examination, testing and treatment (for myself and/or minors under my care).
    • I understand that it may be required at times to remove items of clothing (down to, but not including underwear) for the purpose of assessment, examination and treatment, and give my full informed consent for this.
    • I have read, understood and agree to abide by the DH-Natural Medicine Clinic ‘Terms and Conditions'.
    • I am happy to receive health related information from this practice.

    Thank you for taking the time to answer these questions. Your answers will help me determine the best course of action for your treatment to help you achieve your health goals as fast as possible.