Wellness Consultation Form
Thank you for choosing me! Your journey to better health starts here. Please fill out the following form to help me understand your needs and concerns, I will then be in touch. Thank you
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Age
Phone Number
Please enter a valid phone number.
Format: 00000000000.
Email address
example@example.com
Gender
Occupation
Medical Information
To get a full picture, please complete the following section
Do you currently suffer or have ever suffered / been diagnosed with any of the following conditions or are currently undergoing treatment for:
Asthma
Hayfever
Cancer
Diabetes Type 1
Diabetes Type 2
Pre Diabetic
Acne
Rosacea
Eczema
Psoriasis
Crones
Rheumatitis Arthritis
Psoriatic Arthritis
Lupus
MS
Fibromyalgia
Kidney Disease
Gallbladder Issues
Gallbladder Removal
Ling Conditions
Cardiac Disease
High Blood Pressure (Hypertension)
Low Blood Pressure
Overactive Thyroid (Hyperthyroidism/Graves)
Underactive Thyroid (Hypothyroidism)
Haemophilia
Clotting Disorder
Epilepsy
Abnormal Heart Condition
Heart Attack
Stoke
Addison's
Pre Menopausal/ Menopausal
Hormonal Imbalance
Migraines
Severe Dry Eye Syndrome
Chemotherapy
Radiotherapy
Recent Surgery
Any Other Auto-immune Disorders
Any Other Medical Conditions
If you have ticked any of the above, please give details:-
Do you have a family history of chronic conditions such as diabetes, heart disease or auto immune disorders? If so please specify:
Are you under the care of a doctor or hospital - please give details:
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Do you take pain killers - if so how many, what kind and for what reason?
Are you currently experiencing any of the following symptoms:
Respiratory Issues
Cardiac Disease/issues
Lymphatic
Neurological
Gastrointestinal
Genitourinary
Weight Gain
Weight Loss
Hair Loss
Brittle Nails Or Hair
Musculoskeletal Issues
Headaches & Migraines
Concentration Issues
Depression
Anxiety
Mental Health Concerns
Skin Irritations
Bleeding Gums
Change in Bowl Movement
Joint Pain
Stiffness
Fatigue
Tiredness
Moodswings
Frequent Infections
Other
If you have ticked any of the above, please give details:-
Are you currently taking any medication - if so what are you taking:
Do you have any known allergies to any food, medication or anything else - if yes give details:
Are you currently taking any supplements or collagen - if so what are you taking including brand and dosage:
Dietary Habits
To get the complete picture please answer the following:
What would best describe your current diet: Omnivore (Eat Everything) / Vegetarian / Pescatarian / Vegan / Other / Any Food Intolerances
If you have selected"Other" or "Food Intolerances" - please give more details:
How much water do you drink a day (in mls or litres)?
Do you have sugar cravings?
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Please give details of a typical good day (food and exercise) - including breakfast, lunch, dinner, snacks and drinks:
Please give details of a typical bad day (food and exercise) - including breakfast, lunch, dinner, snacks and drinks:
PHYSICAL HEALTH
How many hours of sleep do you get a night?
What is your sleep quality like and do you feel rested when you wake up?
Do you dream?
Do you wear a sleep monitor?
How would you describe your current stress levels on a scale from 1 to 10 (1 being not stressed and 10 being very stressed)
Do you see an optician regularly?
How often do you visit the dentist?
What infections can you remember, starting as a child that required antibiotics?
How often do you have bowel movements? (For example - once a day, three times a day, once every three days?
Referring to the Bristol Stool Chart - what is the quality of your stool like 1-7 (1 is very hard - 7 is very loose)
Do you have any joint pain?
Do you have any muscle pain?
Do you have any physical limitations or disabilities?
WOMANS HEALTH
CURRENTLY : Trying To Conceive / Pregnant / Breastfeeding / Undergoing or Other Fertility Treatments / I am not Planning a Pregnancy
Type a question
Heading
How active are you on a daily basis - Does your job involve a lot of sitting?
Do you play any sports or participate in any exercise programs?
ADDITIONAL HABITS
Do you smoke/vape? Have you done in the past?
How often do you consume alcohol?
GOALS
Please let us know of your personal goals and targets or specific areas you would like help with.
What are your top health priorities? Improve Energy Levels / Enhancing Heart Health / Enhancing General Health / Improving Sleep Quality / Getting into better Physical Shape / Balancing Blood Sugars / Weight Loss / Weight Gain / Increase in Muscle Mass / General Toning / Working Towards a Competition / Reducing Stress or Fatigue / Other
Regarding your interest in specific wellness tests, please check any that you would like to learn more about:
Zinzino Balance Test - For omega-3levels and fatty acid imbalance/inflamation
HbA1c Test - For Glucose Monitoring
Vitamin D Test - For Vitamin D Levels
Regarding your interest in specific wellness tests, please check any that you would like to learn more about:
Do you have any specific concerns about your current health status, diet, exercise regime, cognitive health or mental wellbeing that you would like to discuss during the consultation
What motivates you to stick with a plan and what barriers have stopped you in the past? (Include potential time commitment issues or accountability issues)
Preferred method of contact
Thank you for completing this form. Our team will review your information and contact you to schedule your consultation.
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