Bioaesthetics Patient Health Questionnaire

Telehealth Consultation with Dr Agnes

.
Patient Questionnaire - Important Information

This questionnaire is designed to gather essential background information before your consultation with Dr Agnes, allowing a comprehensive assessment to be performed within the allocated time at your initial appointment.

Dr Agnes is very mindful of cost constraints, particularly during periods of poor health. To make the most of your consultation, she reviews your responses beforehand and finalises your personalised plan the morning following your appointment.

The more accurate and detailed your responses, the more efficiently your concerns can be addressed during the initial consultation, ensuring that your time and resources are used to the greatest benefit.

Thank you!
Name*

First NameLast Name
Gender*

MaleFemaleNon binary / gender diversePrefer not to say
Email*
example@example.com
Birth Date

MonthDayYear
Signature*
Date*

DayMonthYear
Date
Disclaimer

The information provided in this questionnaire is confidential and will be used solely for clinical purposes. It may be shared with your referring doctor or relevant members of your clinical team when necessary to ensure continuity and quality of care.

How often do you exercise?*

Never1-2 times a week3-4 times a week5-6 times a weekEveryday
If you exercise regularly, please list the type of exercise and how long each session lasts.
Do you smoke?*
Do you consume more than 4 alcoholic drinks per week?*
Would you say you have optimal work-life balance?*
Do you regularly practice self-care, or stress management techniques like meditation, yoga or tai chi ?*
Do you use illicit drugs? Please list which ones and how often
Do you have a pet/s? If so, what type and what is/are their names!

Rows	Details
What was your highest weight & how old were you?
What was your lowest weight & how old were you?
Which plan/s, if any, helped you achieve a stable weight for greater than 2 yeers

Medical and Allied Care
If you were referred to Dr Agnes by a health practitioner or organisation, please note their name below

MEDICAL CARE*

Rows	Y/N	Please list name and specialty where relevant
Do you have a regular GP or regular dr?
Do you have any specialists?
Do you see allied health practitioners?
Have you had blood tests or other tests recently?

Dr Agnes provides a thorough plan that incorporates personalised nutrition, supplements, compounded formulations, prescription medications, lifestyle modifications and evidence-based interventions such as low-level light therapy, vagus nerve stimulation and vibration therapy where relevant. Which of the following advanced protocols would you also like included in your plan:

Stem cells therapiesPlatelet-rich plasmaPeptidesIntravenous nutrientsHyperbaric oxygen therapyTranscranial stimulation or neuromodulationPsychedelic-assisted therapies
Optional: If there is anything else you would like to add, such as how you currently feel, what experiences you've had in the past and what you're hoping to achieve, please note here.

Would you like us to email you a copy of this form?*
Your Preferred email address*
example@example.com
Patient Declaration and Consent:*

I consent to the sharing of relevant information provided in this questionnaire with my referring practitioner and other members of my health care team for the purposes of continuity and coordination of care.I confirm that the information I have provided is true and complete to the best of my knowledge.I agree to discuss any recommendations or treatment plans created with the relevant members of my healthcare team.I understand and agree that the practitioner providing this plan is indemnified against any adverse outcomes arising from the omission or inaccuracy of information supplied, or from actions taken without appropriate medical supervision.
Optional Consent

I consent to the use of information provided in this questionnaire - in a de-identified format - for evaluation, education and research purposes.
Thank you for completing this form. Please tick the box below and press submit!
Should be Empty:

Rows	Yes	If you chose "Yes", please specify the condition and note down treatment including medication doses
Autoimmune condition
Allergies or immune disorder
Thyroid disease
Coeliac Disease or bowel disorder
Food intolerances
Irritable bowel
Diabetes or pre-diabetes
Chronic Fatigue
Arthritis or joint condition
Fatty Liver
Obesity or overweight
Lipedema
Polycystic ovarian syndrome
Endometriosis
Infertility
Menopause or peri-menopause
Osteoporosis or osteopenia
Skin conditions (rosacea, dermatitis, psoriasis, acne, urticaria)
Hair disorders (alopecia)
Adrenal dysfunction or chronic fatigue
Long covid
Neurological condition - seizures, cognitive decline
Stroke or TIA (pre-stroke event)
Heart disease
Kidney disease
Lung disease
Liver disease or hepatitis
Vascular disorder
Lymphatic disorder
Severe infection e.g HIV or TB
Cancer
Currently undergoing chemo or radiotherapy
Severe allergic reactions
A history of anaphylaxis
Epilepsy or seizures
Heavy metal toxicity
Vitamin toxicity
Mould toxicity
Silicone implant disease
Insomnia
Sleep apnoea
Food addiction
Anxiety
Depression
Eating disorder
Post-traumatic stress disorder
Phobias
Psychosis
Alcohol addiction
Drug addiction
Glucose intolerance, insulin resistance
Muscle loss (atrophy)
Hypertension
Hypercholesterolemia
Nutrient deficiencies
Genetic or gene disorders

Rows	0	1	2	3
Sensitivities to chemicals, food, alcohol or environmental triggers - facial flushing, blocked nose, skin rashes, itch
Mouth ulcers
Hair thinning or brittleness
Cold intolerance
Brittle nails
Bleeding gums
Fatigue

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

Rows	0	1	2	3
Frequent or prolonged infections
Recurrent rashes or itching
Nasal congestion
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
Snoring
Cold sores

Telehealth Consultation with Dr Agnes

Rows	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
Low libido
Facial hair in women
Intolerance to cold
Intolerance to warmth

Rows	0	1	2	3
Difficulty concentrating or focusing on tasks
Impaired memory or difficulty retaining information
Brain fog
Cravings for food, alcohol or drugs
Vertigo or dizzy spells
Feeling overwhelmed by small things
A recent change in vision or hearing
Worsening night vision
Ringing in the ears
Altered sense of smell or taste
Trouble falling asleep
Waking between 2am and 4am
Sleep less than 6 hours a night

Rows	YES	NO
Dry or flaky skin
Oily skin
Wrinkles
Pigmentation or discolouration
Broken capillaries
Redness
Saggy skin on face or body
Sensitivity to topical ingredients, heat, exercise or other triggers
Hair loss

Rows	Yes	No
Are you in peri or post menopause?
Have you had children?
Have you experienced issues with fertility ?
Do you experience irregular periods?
Do you experience painful or heavy periods?
Do you experience pre-menstrual syndrome?

Rows	Yes	No
Vegeterian
Vegan
Gluten Free
Dairy Free
Paleo
Ketogenic
Carnivore
Pescaterian
Intermittent fasting
Meal replacement shakes
Ozempic, Wegovy, Monaro or Saxenda
Nutritionist or other practitioners' diet plan