Full Name (required)
Street Address (required)
Postal Address (if different to above)
Email Address (required)
No of children
Years at this occupation
Basic description of job duties: (heavy lifting, typing, etc.)
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
AsthmaCancerDiabetesIDNon IDEpilepsy / SeizuresHepatitisHIV / AIDSHeart DiseaseHigh Blood PressureLow Blood PressureLeukaemiaMultiple SclerosisPoliomyelitisTuberculosisPacemakerJoint ReplacementSurgical ImplantsCar AccidentWorked With Toxic SubstancesRecent Vaccination
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)
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?
Recent Prostate ExaminationRecent Testicle ExaminationProblem Getting an ErectionProblem Maintaining ErectionPremature EjaculationDifficulty Urinating
Pregnant - if so, enter weeks below
Number of Pregnancies
Number of Past Terminations
Age at first period
My Period is usually: HeavyLightPainful
With my Period I also get: PMSDischargeClotting
I am Menopausal: YesNo
Birth Order: (e.g. ... of ...)
APGAR: (... /9)
Term of Pregnancy (weeks)
Feed Straight YesNo
If yes, how many days?
Born with hair YesNo
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 TV, etc. /Day
No. Games, Training/wk
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?
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
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.
5 Eloura Lane, Moss Vale NSW 2577 Australia
Business Hours Mon-Fri 9am – 7pm, Sat 9am – 1pm By appointment only
Phone/fax: (02) 4854 0205 Mobile: 0418 458 548
View our full product range at www.healingremedies.com.au
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