Jellybean Nutrition Client Intake Form

Confidential Client History Form
Full name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Your Mobile Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Emergency Contact's Mobile Phone number*

Area CodePhone Number
Your Home Phone Number

Area CodePhone Number
Doctor's information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Screening Questionnaire

Please answer ALL questions. If you answer YES to any questions please give more details below:*

	Yes	No
SKIN - lesions, eczema, psoriasis, skin cancer, moles or rashes, other?
ENDOCRINE - diabetes, hypoglycaemia, thyroid, pancreas, other?
GASTROINTESTINAL - ulcers, hiatus hernia, reflux, diverticulitis, diarrhoea, IBS, other?
BLOOD -anaemia, thrombosis, anticoagulants, leukaemia, other?
LIVER - hepatitis, jaundice, liver disease/dysfunction, other?
MUSCULOSKELETAL -serious injury, accident, disorders of the back, deformity, loss of strenth, pain, arthritis, other?
NEUROLOGICAL - weakness, numbness, other neuropathy, stroke, seizures, neurological disease genetic or acquired, migraine, other?
RESPIRATORY - asthma, COPD, shortness of breath, CF, emphysema, other?
HEART - rheumatic fever, valves, heart attack, murmur, hypo or hypertension, angina, congestive heart failure, malformation, arrythmias, other?
KIDNEY - kidney eg CKD, nephrotic syndrome, bladder, prostate, dialysis other?
INFECTIOUS OR CONTAGIOUS DISEASE - HIV, hepatitis, Covid, other?
CANCER - unexplained weightloss, treatment for cancer
SURGICAL PROCEDURES - excisions, replacements, repairs, trauma, cosmetic, lifesaving, other?
ALLERGIES - are you allergic to any medications, latex, foods, plasters, if you carry an epipen give details below.
DO YOU SMOKE?
DO YOU DRINK MORE ALCOHOL THAN THE GOV GUIDELINE?
DO YOU ABUSE ANY OTHER SUBTANCES OR USE RECREATIONAL DRUGS?
DO YOU HAVE ANY SIGNIFICANT GENETIC OR OTHER DISEASE WITHIN YOUR BLOOD RELATIONS - eg haemophilia, Sickle Cell, CKD, CF, Huntingdon's disease, BRAC1 gene, other?

If you answered YES to any of the above, please give details here:
Please give as much detail as possible including DATES and OUTCOMES
MEDICATION - please list all the tablets, creams, inhalers, dressings, supplements you take here:
Please give doses of drugs and how often you take them.
(optional) LIFESTYLE - please briefly outline your weekly excercise and whether you feel you live/eat healthy lifestyle.
Why are seeking an consultation with us? eg: painful corn, running injury, low back pain, chronic/acute condition
It is helpful to say when, how it started and how it is affecting you.
Client information - 24 hour cancellation policy

We will ask for the full fee if less than 24 hours notice is given of cancellation unless there are unavoidable extenuating circumstances. You can cancel on-line or by email if necessary.
Client Signature
I have read, understood and completed this questionnaire to my best ability. By signing this form I am consenting to this information being securely digitally stored in compliance with Jenni Dean, Jellybean HWC. We will not share this information with any third parties without your written consent. I further agree to Jellybean Nutrition Privacy Policy as everything written and spoken will be confidential.
I am happy to receive:

text reminders about my appointmentimportant announcements via email or SMS (eg Christmas hours, unexpected closure)announcements about new services/or offers (eg gift vouchers, introducing new staff)
Signature*

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MonthDayYear
Date
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Confidential Client History Form

Health Screening Questionnaire

Client information - 24 hour cancellation policy

Client Signature