Initial Consultation Form

Initial Consultation Form
Name*

PrefixFirst NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date Of Birth

MonthDayYear
Date
Gender

FemaleMale
Current Health Care Practitioners
Occupation
Height & Weight
Emergency Contact Name & Number
Current Medications & Supplements
Medical History
Presenting Health Concern & Current Treatment
Family Medical History
Childhood Health/ Other Medical Conditions
Allergies Or Sensitivities
Body Systems Review: Please Tick Below If Applicable
Digestive System

Mouth ulcersBleeding gumsBad breathTasteCracked lipsTeeth problemsExcessive hungerHeart burnIndigestionBurpingVomitingFlatulenceConstipationDiarrheaHaemorrhoidsCrampingBloatingPainOther
Cardiovascular System

High blood pressureLow blood pressureChest painPalpitationsAnginaDysrhythmiaDizziness on standingPain on exerciseFaintingOedema in legsPoor circulationCold hands or feetFluid retentionSwollen anklesNumbness or tinglingVaricose or spider veinsHot flushesLeg crampsOther
Nervous System

HeadachesMigrainesTensionVertigo/ dizzinessNeck painLight headedEar infectionsEar dischargeDeafnessEaracheTinnitus/ ringing in earsParalysisBlack outsLoss of sensationTremorsSleep difficulties (specify in Other)Other
Respiratory System

SinusitisHayfeverColdsNose bleedsPost nasal dripNasal stuffnessAsthmaWheezingShortness of breathSputumCoughBronchitisPneumoniaEmphysemaPleurisy/ tuberculosisOther
Urinary System

UTI's/ CystitisPain passing urineNocturiaStonesFrequent urinationUrgency to urinateBurning passing urineIncontinenceOther
Muscular & Skeletal System

Injuries (specify in Other)PainStiffnessSciaticaBroken bonesArthritisCrampsOther
Immune System

InfectionsLow healing timeSwollen glandsSwellingFrequent infectionsGlandular fever past or presentViruses (specify in Other)Frequent colds or fluOther
Endocrine System

Thyroid (specify in Other)Diabetes type 1Diabetes type 2Excessive hunger or thirstPolyuriaHyoglycaemiaWeight gainWeight lossCravingsFatigueOther
Integumentary System (Skin)

DryOilyAcnePsoriasisEczema/ dermatitisPimplesFungal infectionsCold soresAlopeciaHair greyingOther
Emotional & Psychological Review

Panic attacksAnxietyPhobiasDepressionMood changesOther
Female Reproductive System

Irregular menstrual cycleHeavyBloatingPMSCrampingPainMenopausePoor libidoMiscarriagesDifficulty falling pregnantInfectionsThrush/ candidaDrynessSTD'sWartsHerpesPCOSEndometriosisFibroidsCystsDysmennhorreaPregnant or possibly could beCurrently trying to conceiveOn the oral contraceptive pill (specify in other for how long)Have taken oral contraceptive pill in past (specify in other when and duration)Other
Male Reproductive System

ProstateInfectionsSTD'sLow libidoPainful urinationOther
Current Number Of Children
Rate Energy Levels: 1 (low) to 10 (high)
Do you follow a particular diet? (e.g. vegetarian, vegan, paleo, other).
Sample Daily Diet
Cigarette Smoker

Yes (amount per week in Other)NoSociallyOther
Alcohol

Yes (amount per week in Other)NoOther
Additional Information
Please bring along any blood test results or medical scans and reports if you have any. You can also email them to inspiredbywellness@outlook.com beforehand.
I understand and give full permission for my information to be kept on file securely and with the strictest of confidentiality*

Yes I give full permission
I agree that at times I will communicate with Inspired By Wellness via email. This means that my personal information, consultation forms, medical reports or test results may be communicated or sent via email.*

Yes I give full permission
I understand that my appointment will be secured once a minimum deposit of 25% of the consultation fee has been made. I agree that this is non-refundable if less than 48 hrs notice is given for rescheduling or cancelling.*

Yes I understand and give full permission
Please select one option for your payment from below. Your appointment will only be secured after a deposit has been made. In clinic payment options for the remaining balance and prescriptions include: Credit card, eftpos, cash or bank transfer.
1. Online Booking or Phone: Appointment was made via the online booking system or over the phone and a 25% deposit/ full payment was made at time of booking.*

YesNo - choose option 2, 3 or 4
Or
2. Bank Transfer: Select option below, and transfer to the following- Commonwealth Bank, Dianna Bedran Trading As Inspired By Wellness, BSB 062-190 ACC 10619524. Email receipt to inspiredbywellness@outlook.com.

Initial consultation in clinic appointment, deposit $50 or pay in full $215Initial consultation via video or phone call to be paid in full $215The Wellness Package to be paid in full $575
3. Credit Card: If you prefer to pay via credit card, an over the phone payment can be arranged.

Call Inspired By Wellness on 0416838379 to arrange payment.
An email will be sent to you after submitting this form, it has a Welcome Letter attachment containing general clinic info. and another email with a consent form if you have selected to have the appointment via Zoom or phone call.

Please check all your email inboxes to ensure you receive all emails from Inspired By Wellness, including confirmation booking emails from our booking system.

Thank you for completing this form. Your wellbeing is important to us. Your email will be automatically added to our mailing list for our occasional newsletter containing free recipes and wellness advice. You may unsubscribe at any time via the link provided within the newsletter.

Please click Submit below when finished.
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Initial Consultation Form

Body Systems Review: Please Tick Below If Applicable