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Health Check Form
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Health Check Form
Telephone 03 95910202 or 1800673180
You can photograph your Prescription and SMS it to 0403175339
First Name
Last Name
Email
Phone Number
Age
Your Gender
Male
Female
Primary health complaints
Describe your symptoms, including frequency and duration.
When did they start?
Is there anything that makes them better or worse?
Is there a family history of these symptoms?
Please list any allergies you have:
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Diet & Lifestyle
How many hours do you sleep at night?
What is the quality of your sleep? (One a scale of 1 to 10 | Where 10 is best)
1
2
3
4
5
6
7
8
9
10
Overall diet (One a scale of 1 to 10 | Where 10 is healthiest)
1
2
3
4
5
6
7
8
9
10
How many cigarettes do you smoke a day?
How many standard drinks do you consume per week?
How many times a week do you exercise? What sort of exercise / activity do you do?
Medical Conditions - Do you have any of the following?
Arthritis
Yes
No
Asthma
Yes
No
Chemical sensitivities
Yes
No
Coeliac disease
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Glaucoma
Yes
No
Heart condition
Yes
No
High blood pressure
Yes
No
Inflammatory Bowel Disease
Yes
No
Lactose intolerance
Yes
No
Stomach ulcers
Yes
No
Thyroid conditions
Yes
No
List any other medical conditions you may have:
Please list any medications you're currently taking:
Please list any supplements you're currently taking:
The information I provided regarding my health is accurate
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