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Health Check Form

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Health Check Form

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)

Overall diet (One a scale of 1 to 10 | Where 10 is healthiest)

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

Health Check Form

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