HEALTH QUESTIONNAIRE

Health Evaluation Form

The following questionnaire is a comprehensive look at your health. It will take about 10 minutes to complete
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemaleOther
Other - Please specify
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Height*
Weight *
Goal Weight *
Name of Doctor or other health professionals you are currently seeing*
Medical Disclaimer

This Health Questionnaire will be assessed by Dr Agnes and used solely to identify potential nutrient deficiencies or assess your suitability for participation in the health or weight loss programs offered by BioAesthetics. Please answer each question carefully and attach the results of any recent blood tests. It is important to understand that a medical examination or referral for tests are not included in this assessment, therefore Dr Agnes cannot diagnose any medical conditions. By signing the form below, you agree to see your GP for a thorough assessment of your symptoms and discussion of management options prior to commencing the recommendations provided as part of this assessment.

I, {fullName538} , understand that the information provided below will be assessed by a doctor solely for the purpose of determining my suitability to participate in one of the programs offered by BioAesthetics. I agree to see my GP to exclude any medical conditions that may be causing my symptoms and to follow up on any findings that are beyond the scope of this assessment.

I acknowledge that the information provided below is correct and complete. I take full responsibility for any complications arising from withholding information or from following the recommendations provided as part of this assessment.
Signature*

Clear
Date*

MonthDayYear
Date

	Yes	No
Are you menopausal?

	Yes	No	If Yes, list year of each pregnency
Have you had children?

	Yes / No
Dry or flaky skin
Oily skin
Wrinkles
Pigmentation or discolouration
Broken capillaries
Redness
Saggy skin on face or body

Do you exercise?*

Never1-2 times a week3-4 times a week5-6 times a weekEveryday
Please list the types of exercise you do regularly*
Do you smoke?*
How many per day?
Do you work?*
if yes, what do you do?
Are you in relationship?*
if yes, please describe?
Do you have children?*
if yes, how old are they?
Do you live near powerlines?*
Do you live near mobile phone towers?*
Is there any water damage, musty smell or obvious mould in your home?*
How long are you on your mobile phone daily?*
On average, how long are you at your computer daily ?*
Do you have dental amalgam fillings?*
if so, please list the type/s*
Have you ever been diagnosed with heavy metal toxicity?*
Do you take recreational drugs? *
if yes, please list what drugs and how often?*
How many glasses of water do you have a day
Do you drink alcohol?*

YesNo
How many drinks per week?*

Diet Preferences
Do you follow any of these of dietary plans?
Vegetarian*
Vegan*
Gluten Free*
Dairy Free*
Paleo*
Ketogenic*
Carnivore*
Pescaterian*
Intermittent fasting*
Do you follow other dietary plans?
Other. Please list*
Do you have any food allergies / intolerances that you are aware of?
Please list any food allergies / intolerances that you are aware of?*
DIET HISTORY

What do consume on a regular day (be specific & note portion sizes and meal times*

	Do you have?	Time	Details
Breakfast
Snack
Lunch
Snack
Dinner
Snack

Do you diet often?:*
Are you unhappy with your weight?:*

OTHER*

	Details
What was your highest weight & how old were you?
What was your lowest weight & how old were you?
What diets have you tried to lose weight?
Do you exercise regularly? What type & how often?

PSYCHOLOGICAL ASSESSMENT

Have you been diagnosed with any of the following? (please note details):*

	Y / N	Date & Treatment
Anxiety
Depressions
Schizophrenia or bipolar
Post-traumatic stress disorder
Panic attacks or disorder
Phobias
Personality disorder
Eating disorder

MEDICAL CARE*

	Y / N	Name and approximate last date assessed
Do you have a regular GP or regular dr?
Do you have any specialists?
Do you see a psychiatrist?
Do you see allied health practitioners?
Have you had blood tests recently?
Have you had any other tests?
Do you regularly see a Dentist?
Do you have mercury amalgams?

In order to avoid additional fees, please provide a copy of results for any blood tests you have had in the last 12 months*

Browse Files
*Dr Agnes will only refer for privately-billed tests. If you haven't had any general blood tests ordered by you GP, it is advisable that you do so - and forward the results - prior to your consultation with Dr Agnes. Cancelof
Please acknowledge all of the following
I underestand that: ( Please tick all fields)*

By enlisting Dr Agnes Warchalowski’s services I will obtain guidance related to weight management, anti-ageing tools and methods to assist certain physiological processesConsultations with Dr Agnes Warchalowski do not involve investigation, diagnosis or management of my medical conditions or symptoms.Prior to my consultation, I must see my GP to investigate and/or manage my symptoms and/or medical condition/s.After my consultation, I must continue to see my GP for management of my symptoms and/or medical condition/s.The Initial Health Consultation will determine the best path of management for me, and the $150 fee will be deducted from the service I proceed with - that is one of the health programs.I will not be prescribed pharmaceuticals, referred to specialists or for bulk-billed testing, however, Dr Agnes may refer for privately-billed tests or make recommendations that I can discuss with my GP.If I choose to proceed with one of the health programs (BiomeMD and hCG Diet), I will be provided with a comprehensive written plan.

Would you like us to E-mail you a copy of your HQ?*
Your Preferred E-mail Address*
example@example.com
Should be Empty:

	Yes/No	Please specify condition	Treatment
Autoimmune condition
Allergies or immune disorder
Thyroid disease
Coeliac Disease or bowel disorder
Diabetes or pre-diabetes
Polycystic ovarian syndrome
Adrenal dysfunction or chronic fatigue
Obesity
Fatty Liver
Skin conditions (rosacea, dermatitis, psoriasis, acne)
Hair disorders (alopecia)
Menopause
Chronic Fatigue
Neurological condition - seizures, cognitive decline
Arthritis or joint condition
Heart disease
Kidney disease
Lung disease
Liver disease or hepatitis
Severe infection e.g HIV or TB
Sleep apnoea
Vitamin toxicity
Cancer
Currently undergoing chemo or radiotherapy
Severe allergic reactions
A history of anaphylaxis
Epilepsy or seizures

	0	1	2	3
Sensitivities to chemicals, food or environmental Rashes or itch
Mouth ulcers
Hair thinning or brittleness
Facial or neck flushing with alcohol, certain foods or chemicals
Cold intolerance
Heat intolerance

	0	1	2	3
Bloating, fullness or indigestion after a meal
Heartburn or reflux
Constipation
Nausea or vomiting
Abdominal cramps or aches
Excessive gas
Diarrhoea or frequent bowel movements

	0	1	2	3
Frequent infections
Recurrent rashes or itching
Nasal congestion or discharge
Joint pain or stiffness
Swollen hands or feet in the morning
Swollen feet at the end of the day
Puffy eyelids or dark circles
Fatigue

	0	1	2	3
Fatigue, sluggishness
Feeling cold
Weight gain
Fluid retention
Hair loss
Loss of muscle mass

Health Evaluation Form

GENERAL INFORMATION

Next: Lifestyle . .

Diet Preferences

	0	1	2	3
Shaky or irritable between meals
Waking hungry at night
Cravings for sugar, coffee or chocolate
Low mood, stressed or mood swings
Night sweats
Hot flushes
Fatigue easily
Acne
Hair loss or brittleness
Rapid skin ageing or wrinkling
Loss of muscle mass
Facial hair in women

	0	1	2	3
Difficulty concentrating or focusing on tasks
Impaired memory or difficulty retaining information
Brain fog
Cravings for food, alcohol or drugs
Insomnia or waking at night
Feeling overwhelmed by small things
A recent change in vision or hearing
Worsening night vision

	Medical Condition	Year Diagnosed	Treatment
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3
4
5
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