Integrative Health Assessment Form
Please complete all sections to provide a thorough overview of your personal, medical, and lifestyle history. *if unable to answer, type "NA" into the field
Section 1 — Personal Details
Tell us about yourself.
Full Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Gender
*
Male
Female
Other
Email or Phone
*
Section 2 — Birth & Early Life
Information about your birth and early years.
Maternal age (your mother's age at your birth)
Maternal illnesses during your mother's pregnancy with yourself
Maternal tobacco use during your mother's pregnancy with yourself
Yes
No
Maternal alcohol use during your mother's pregnancy with yourself
Yes
No
Maternal drug use during your mother's pregnancy with yourself
Yes
No
Type of delivery
Vaginal
C-section
Assisted
Gestational age at your birth (weeks)
Were you breastfed as an infant
Yes
No
Were you vaccinated as an infant
Yes
No
Birth order (e.g., 1st, 2nd child)
Number of siblings
Early Life Social Situation: Was your home a happy, healthy space?
Where you were living (early life)
Additional comments about birth & early life
Section 3 — Childhood
Information about your childhood health and social environment.
Childhood Health: Developmental issues (reading, writing, walking, talking etc)
Accidents, injuries, or fractures during your childhood
Food intolerances you had as a child
Hand dominance
Right-handed
Left-handed
Ambidextrous
Recurrent Ear infections
Yes
No
Recurrent Tonsillitis
Yes
No
Asthma
Yes
No
Eczema
Yes
No
Hay fever
Yes
No
Constipation in Childhood
Yes
No
Hospitalisations during your childhood
Neurodivergence (e.g., ADHD, autism)
Yes (please provide details below)
No
If yes to neurodivergence, please provide details
Section 4 — Teen Years
Information about your health and experiences as a teenager.
Illnesses during teen years
Age you left school
Drug use during teen years
Yes (please provide details below)
No
If yes to drug use, please provide details
Alcohol use during teen years
Yes (please provide details below)
No
If yes to alcohol use, please provide details
Smoking during teen years
Yes (please provide details below)
No
If yes to smoking, please provide details
Mental health during teen years
Eating disorder symptoms (teen years)
Hospitalisations during teen years
Section 5 — Adulthood
Medical history and relationships in adulthood.
Mental health history (adulthood)
Other significant medical issues/accidents/surgeries (adulthood)
Section 6 — Women Only
Please complete this section if applicable.
Menarche (age at first period)
Cycle issues
Cycle length (days)
Period pain (scale 1–10)
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Heavy bleeding during periods
Yes
No
Menses description
Pill use (contraception)
Yes
No
Other contraception
Menopause
Yes
No
Menopause symptoms
Number of pregnancies
Number of children
Conception and Pregnancy Details- natural conception vs IVF, delivery details
Ages during pregnancies
Pregnancy issues
High blood pressure
High blood sugar
Low iron
Other
Breastfeeding (most recent)
Yes
No
Recovery after birth
Signs of postnatal depression
Yes (please provide details below)
No
If yes to postnatal depression, please provide details
Section 7 — Lifestyle & Environment
Tell us about your lifestyle and environment.
Countries you have travelled to
Illnesses during travel
Pets
Toxic exposures
Mould
Industrial areas
Passive smoking
Workplace hazards
Other
Vaccinations (up to date)
Yes
No
Section 8 — Family History
Check any family history of the following conditions and provide details if applicable.
Family history of health conditions (check all that apply and add details if needed)
Heart disease
Breast cancer
Bowel cancer
Skin cancer
Prostate cancer
Diabetes
Osteoporosis
Other
If any other important family history, please provide details
Section 9 — Preventative Health Screening
Let us know about your preventative health screening.
Cervical screening up to date?
Yes (please provide results below)
No
Cervical screening results (if applicable)
Breast cancer screening (have you had this?)
Yes (please provide results below)
No
Breast cancer screening results (if applicable)
Bowel cancer screening (have you had this?)
Yes (please provide results below)
No
Bowel cancer screening results (if applicable)
Skin cancer screening (have you had this?)
Yes (please provide results below)
No
Skin cancer screening results (if applicable)
Prostate cancer screening (have you had this?)
Yes (please provide results below)
No
Prostate cancer screening results (if applicable)
Family history notes (preventative health)
Any issues found during screening
Section 10 — Additional Comments
Share anything else you’d like us to know.
Anything else you’d like to share?
Consent to share investigations with other health professionals?
Yes
No
Submit Assessment
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