Medical History
Please complete before our consultation. If there are questions that you would prefer not to answer or you do not know the answer then just leave them blank.
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
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Occupation
How did you hear about me?
Contact Information
Address:
*
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail that we will use to regularly communicate with you
Can we contact you over email regarding your appointments and/or questions you may have?
Please Select
Yes
No
Preferred phone number for voice and/or text communication
*
-
Country Code
Phone Number
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Health Information and History
Name of General Practitioner or Doctor
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postal
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Do you give permission for me to discuss your medical history and treatment with your GP?
Yes
No
If you have a current health condition, or have been diagnosed with one in the past, please list below (eg. diabetes, cancer, IBS etc...)
Any history of surgery or hospitalizations?
Yes
No
Please indicate if you have had any of the following concerns in the past year, or of significance in the past.
Muskuloskeletal
Joint Pain
Muscle Pain
Stiff joints
Headaches
Skin
Acne
Eczema
Psoriasis
Hives
Athletes foot
Other rash
Nose and Sinus
Sinus infections
Sinus pain
Hay fever
Runny nose
Mouth and Throat
Sore throat
Gum problems
Tooth pain
Cold sores
Trouble swallowing
Strep throat
Dry/cracked lips
Cardiovascular System
High Blood Pressure
Angina/Chest Pain
Heart Disease
Cold Hands/Feet
Clotting Disorder
Varicose veins
Respiratory
Shortness of Breath
Tight or congested chest
Wheezing
Cough
Asthma
Neurological
Fainting
Dizziness
Numbness/Tingling
Seizures
Headaches or migraines
Memory Loss
Problems with sleep
Endocrine System
Hypothyroidism
Hyperthyroidism
Sugar cravings
Type 1 Diabetes
Type 2 Diabetes
Digestive System
Stomach Pain
Nausea
Vomiting
Heart Burn
Gas
Change in Appetite
IBS
Inflammatory bowel disease
Coeliac Disease
Gall Bladder removed
Haemorrhoids
Diarrhoea
Constipation
Urinary System
Pain on urination
Urgency
Increased Frequency
Inability to hold urine
Kidney stones
Getting up in the night to pass water
Problems starting or stopping urination
Other
Immune System
Frequent colds/flus
Cancer
Allergies
Auto-immune disease
Mental/Emotional Health
Depression
Anxiety
Insomnia
Mood Swings
Anger/Frustration
Irritability
Phobias
Panic Attacks
Please list anything else, or elaborate on the above if you would like.
Please indicate if any of your family members currently have a health condition, or have had one in the past
Rows
Mother
Father
Brother
Sisters
Maternal Grandparent
Paternal Grandparent
Allergies
Asthma
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Liver Disease
Kidney Disease
Anxiety
Depression
Other mental health issue
Addiction or alcoholism
Other, please specify
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Health Assessment and Medical Information
Current Height
Current Weight
Has your weight ever fluctuated by more than 10lbs in a short period of time?
Yes
No
I have struggled with my weight now for years
Details, if applicable
Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..
Yes
No
Please give details of all medications here:
Are you taking any supplements, minerals/vitamins, herbs or other natural health care products?
Yes
No
Please give details of all supplements etc here:
Any known allergies?
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Dietary and Lifestyle Habits
How often do you exercise?
Rows
0
1
2
3
4
5
6
7
Times per week
What kind of exercise?
Do you have any known (or suspected) food allergies or intolerances?
Yes
No
Please list:
Do you have any dietary restrictions? (eg. religious, vegan/vegetarian)
Yes
No
Please specify
Please describe a typical day's diet
Breakfast
Lunch
Dinner
Snacks
Average number of bowel movements per day
Do you experience any of the following (check all that apply)
Straining
Blood in stool
Mucus in stool
Diarrhea
Constipation
Please indicate how many cups of the following you drink per day,based on a standard mug size.
Rows
0
1
2
3
4
5
6
7
8
9+
Water
Coffee
Tea
Herbal Tea
Juice
Cola
Do you consume alcohol?
Yes
No
Average number of units per week (2 units are roughly equivalent to a medium glass of wine or a pint of standard strength beer or lager)
Rows
1-5
6-10
11-15
16-20
21+
Select one
Do you smoke tobacco?
Yes
No
In the past
For how many years?
How many years ago did you quit?
Average number of cigarettes/day (currently or in the past)
Rows
1-5
6-10
11-15
16-20
21-30
31-40
41+
Select one
Are you regularly exposed to second hand smoke?
Yes
No
I don't know
Do you use recreational drugs?
Yes
No
Please list which kinds, and how often.
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Home Environment
Do you live close to any of the following?
Airport
Highway
Dump/Landfill
Industrial area
Farm/Agricultural area
How old is your home?
How many years have you lived there?
Have you done any recent renovations to your home?
Yes
No
Please describe (e.g. painting, new carpets etc)
Do you have any household pets?
Yes
No
Type of pet:
Sleep, Energy and Stress Levels
Please rate your energy level on a scale from 1-10
1
2
3
4
5
6
7
8
9
10
Lowest
Highest
1 is Lowest, 10 is Highest
On average, how many hours of sleep do you get?
Less than 5
5-7
8-9
9-11
Do you have difficulty falling asleep?
Yes
No
Sometimes
Do you have difficulty staying asleep?
Yes
No
Sometimes
Do you nap during the day?
Yes
No
Sometimes
Please rate your stress level on a scale from 1-10
1
2
3
4
5
6
7
8
9
10
Lowest
Highest
1 is Lowest, 10 is Highest
What are some stressors in your life?
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Women's Health
Men please skip to the next page
Age of first menstrual period
Date of last menstrual period
-
Day
-
Month
Year
Date
How long is your typical menstrual cycle (days between your period)
How many days is your period?
Do you experience any of the following?
Rows
Always
Sometimes
Never
Heavy flow
Clots
Bleeding between periods
Missed periods
Breast tenderness
Cramps
PMS
Emotional changes
Pain during sex
Are you currently breastfeeding?
Yes
No
Are you currently pregnant?
Yes
No
Possibly
Are you trying to become pregnant?
Yes
No
Are you currently sexually active?
Yes
No
How many times have you been pregnant?
Please give your current method of contraception, if applicable
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Men's Health
Women please skip to the next page
Are you sexually active?
Yes
No
Please give your current method of contraception, if applicable
Do you have any problems with erectile dysfunction
Please Select
Yes
No
I am currently taking something for this
Do you experience painful or difficult urination?
Yes
No
Sometimes
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Please quickly rate your level of satisfaction with the following areas of your life.(1 star = not satisfied, 5 star = very satisfied)
Health
1
2
3
4
5
Any comments
Diet
1
2
3
4
5
Any comments
Occupation
1
2
3
4
5
Any comments
Fitness Level/Physical Activity
1
2
3
4
5
Any comments
Living/Home Environment
1
2
3
4
5
Any comments
Family and Friends
1
2
3
4
5
Any comments
Romantic partnership/Significant Other
1
2
3
4
5
Any comments
Is there anything else you would like to add that you feel is important and has not been covered?
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