Initial Consultation Form

Initial Consultation Form
Name *

Prefix First Name Last Name
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Date
Gender

Female Male
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 ulcers Bleeding gums Bad breath Taste Cracked lips Teeth problems Excessive hunger Heart burn Indigestion Burping Vomiting Flatulence Constipation Diarrhea Haemorrhoids Cramping Bloating Pain Other
Cardiovascular System

High blood pressure Low blood pressure Chest pain Palpitations Angina Dysrhythmia Dizziness on standing Pain on exercise Fainting Oedema in legs Poor circulation Cold hands or feet Fluid retention Swollen ankles Numbness or tingling Varicose or spider veins Hot flushes Leg cramps Other
Nervous System

Headaches Migraines Tension Vertigo/ dizziness Neck pain Light headed Ear infections Ear discharge Deafness Earache Tinnitus/ ringing in ears Paralysis Black outs Loss of sensation Tremors Sleep difficulties (specify in Other) Other
Respiratory System

Sinusitis Hayfever Colds Nose bleeds Post nasal drip Nasal stuffness Asthma Wheezing Shortness of breath Sputum Cough Bronchitis Pneumonia Emphysema Pleurisy/ tuberculosis Other
Urinary System

UTI's/ Cystitis Pain passing urine Nocturia Stones Frequent urination Urgency to urinate Burning passing urine Incontinence Other
Muscular & Skeletal System

Injuries (specify in Other) Pain Stiffness Sciatica Broken bones Arthritis Cramps Other
Immune System

Infections Low healing time Swollen glands Swelling Frequent infections Glandular fever past or present Viruses (specify in Other) Frequent colds or flu Other
Endocrine System

Thyroid (specify in Other) Diabetes type 1 Diabetes type 2 Excessive hunger or thirst Polyuria Hyoglycaemia Weight gain Weight loss Cravings Fatigue Other
Integumentary System (Skin)

Dry Oily Acne Psoriasis Eczema/ dermatitis Pimples Fungal infections Cold sores Alopecia Hair greying Other
Emotional & Psychological Review

Panic attacks Anxiety Phobias Depression Mood changes Other
Female Reproductive System

Irregular menstrual cycle Heavy Bloating PMS Cramping Pain Menopause Poor libido Miscarriages Difficulty falling pregnant Infections Thrush/ candida Dryness STD's Warts Herpes PCOS Endometriosis Fibroids Cysts Dysmennhorrea Pregnant or possibly could be Currently trying to conceive On 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

Prostate Infections STD's Low libido Painful urination Other
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) No Socially Other
Alcohol

Yes (amount per week in Other) No Other
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: Afterpay, 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. *

Yes No - 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 deposit $50 or pay in full $175 Initial consultation via video or phone call to be paid in full $175 The Wellness Package to be paid in full $485
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.
Or
4. PayPal Available For Initial Consultation

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AUD For in clinic consultations, please pay either a deposit of $50.00 or pay in full $175.00. Video/ phone call consultations need to be paid in full.

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An email will be sent to you after submitting this form, it has a Welcome Letter attachment containing general clinic info.

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.

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Initial Consultation Form

Body Systems Review: Please Tick Below If Applicable