Your Health Matters

In order to provide you with the highest quality of health care, please provide the following information regarding your present state of health and medical history. Please note that all of this information is required to make an accurate assessment of your individual needs and to help you achieve the best possible results. The information you provide is completely confidential.

 

Please complete the form below

Name *
Name
Date *
Date
Address *
Address
Date of Birth *
Date of Birth
Goals & Expectations
1 = very poor 10 = excellent
1 = very poor 10 = excellent
1 = very poor 10 = excellent
Medical History
Date of last physical examination with your doctor:
Date of last physical examination with your doctor:
Date of last pathology with your doctor:
Date of last pathology with your doctor:
Present Health
Medical Checklist
Please indicate if you suffer from any of the following conditions and please include severity.
Please list all the prescribed medications (including medications taken regularly or on occasion) and / or supplements (including herbal and vitamin supplementations) that you are currently taking. Please list when you take these and dosage.
Chest tightness, shortness of breath on stress / exertion *
Palpitations, arrhythmias, extra heart beats *
Fluid retention, swollen ankles *
Calf pain on exercise *
Dizziness on exertion *
Previous angina attacks, heart attack or stroke *
Blood clotting problems *
Low blood pressure, dizziness on standing *
Asthma, wheezing on exertion *
Chronic cough *
Sweating / tremors / shakiness / headaches / irritability if food is delayed *
Less than 1 bowel movement daily *
History of constipation, diarrhea / loose stools *
Frequent antibiotic use *
Inflammation of the bowel *
Food intolerances / allergies *
Heart burn, stomach ulceration *
Sensitivity to cold *
Sensitivity to heat *
Slow healing wounds *
Reoccurring infections *
MS, SLE or autoimmune diseases *
History of anorexia, bulimia, eating disorders *
Depression, anxiety, bipolar disorder, any other mental health conditions *
Abnormal liver function tests, hepatitis *
Gallstones, pain under right side of ribs *
Fatigued all the time, chronic fatigue *
Headaches, migraines *
High sensitivity to chemicals *
Inflammatory condition *
Difficulty in losing weight *
Frequent urination *
Smelly, cloudy urine *
Frequent urinary tract infections *
Menstrual irregularities *
Premenstrual Syndrome, Premenstrual Tension *
Please state whether there is any other health concern that may be of relevance before commencing this program.