Date YOUR DETAILS
Title Dr Mr Mrs Ms Miss
First Name *
Preferred first name (if different to above)
Please include the area code for home and work phone numbers.
Which of the above phones is your preferred method of contact?
Email Address *
Emergency Contact Person *
Their Phone *
How did you find about the Clinic? * Google Ad or similar Internet search for Passing by Flyer or brochure Gift Voucher 4074 Community Facebook page I was referred to the Clinic Other
If you found out about us from an internet search, please advise what you searched for *
If you were referred to our Clinic, please advise the full name of the person who referred you *
If for the previous question you answered ‘Other’, please detail how you heard about our Clinic * What type of therapy (or therapies) would you prefer? Plus Free Health Assessment (value $120)
Do you have a preference for a particular therapist? Which one? What level of care would you prefer? I have a particular problem that I would like seen to (Symptomatic Care). I have a particular problem that I would like seen to, and I want to stop the problem coming back again in the future (Corrective Care). I have a particular problem that I would like seen to, and I want to look after my health and enjoy a long healthy life (Corrective and Rejuvenation Care).
My long-term health goals are Would you like a reminder the day before an appointment? Cancellation Policy: Our policy is that any missed appointments, or appointments cancelled with less than 24 hrs notice, must be paid for. (Please note that not receiving a SMS or an email reminder will not be accepted as a reason for missing an appointment.) I confirm that I understand and accept this policy * Main health problem/ complaint
When did it start? *
Did it come on suddenly or gradually? Suddenly Gradually
Have you had this problem before? (Please detail)
Is there anything that makes it worse or improves it, eg heat? Health History
What operations have you had, and when? *
What significant illnesses have you had (including glandular fever and childhood illnesses)? *
What medication or tablets do you take? *
Do you have any infectious disease, eg hepatitis, HIV, shingles? (Please detail) *
What health issues is there a history of in your family? (Please list) General health
How are your energy levels?
How is your appetite? Do you smoke? How much of the following would you have a week?
How often do you move your bowels?
Do you pass urine more frequently than normal?
Do you get to sleep easily?
Do you wake up during the night? (Please detail) Do you experience any of the following? If so, please state what tends to make it worse, or when you tend to get it.
Please Describe Digestive Problem (please detail)
Please Describe Constipation or diarrhoea
Please Describe Dizziness/ ringing in the ears
Please Describe Palpitations (increase in heart rate for no reason)
Please Describe High or low blood pressure
Please Describe Any unusual taste in your mouth (bitter, metallic, etc)
Please Describe For women
Are you pregnant?
How long does your period last? (days)
How long is your cycle? (e.g. 28 days)
Is your period normal, heavy or light?
Do you get pain with your periods? If so, when?
Is the pain
What other symptoms do you get?
What stage of your period do you get them?
Where are you in your cycle? Do you experience any other health problems?
Please detail these problems.
Please detail these problems. 2
Please detail these problems. 3 To provide you with the best possible care, do you agree to allow discussions or information to be shared between Health Professionals within the clinic for the purpose of improving your health and well-being? *