Date
YOUR DETAILS
Title
Dr
Mr
Mrs
Ms
Miss
First Name
*
Surname
*
Preferred first name (if different to above)
Address
*
Suburb
*
Postcode
*
Home Phone
Work Phone
Mobile
Please include the area code for home and work phone numbers.
Which of the above phones is your preferred method of contact?
Email Address
*
Occupation
Health Fund
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?
Do you have a preference for a particular therapist? Which one?
What level of care would you prefer?
My long-term health goals are
Would you like a reminder the day before an appointment?
Cancellation 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?
Coffee
Alcohol
Chocolate
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
Please Describe
Please Describe
Please Describe
Please Describe
Please Describe
Please Describe
Please Describe
Please Describe
Please Describe
Please Describe
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
Other
What other symptoms do you get?
Other
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
If you are human, leave this field blank.
