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?
Emergency Contact Person
How did you find about the Clinic?
Google Ad or similar
Internet search for
Flyer or brochure
4074 Community Facebook page
I was referred to the Clinic
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?
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?
Have you had this problem before? (Please detail)
Is there anything that makes it worse or improves it, eg heat?
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)
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.
Digestive Problem (please detail)
Constipation or diarrhoea
Dizziness/ ringing in the ears
Palpitations (increase in heart rate for no reason)
High or low blood pressure
Any unusual taste in your mouth (bitter, metallic, etc)
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?