Health Questionnaire
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Check the conditions that apply to you or to any members of your immediate relatives:
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Asthma
Cancer
Cardiovascular disease
Diabetes
Hypertension
Mental health
Neurological condition
Other
Have you been diagnosed with any specific illnesses, and if so, when? Please list and describe.
*
Have you received any previous treatment for these illnesses? Please explain.
*
Have you had any surgeries? If yes, please list and explain.
*
Have you had any pathology testing/scans in the last 12 months? Please list and explain.
*
Please bring these results with you to your first consultation, or alternatively, you can email them to lina@nourishmindbodynutrition.com.au prior to your consultation. Thank you.
Check the symptoms that you're currently experiencing:
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Respiratory concerns
Cardiovascular/circulation concerns
Gastrointestinal/digestive discomfort
Urinary concerns
Weight gain
Weight loss
Stress/anxiety/depression
Poor sleep
Headaches/migraines
Fatigue/lethargy/lack of energy
Joint/muscle injury/aches & pains
Female menstrual cycle concerns
Reproductive support
What is your primary concern and reason for consulting a nutritionist?
*
What are your goals for this consultation and moving forward?
*
Are you currently taking any medication and/or supplements?
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Yes
No
If yes, please specify the product and dosage.
*
Do you have any known allergies?
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Yes
No
Do you have any known food intolerances?
*
Yes
No
If yes, please specify and explain how this was diagnosed.
*
Do you have any other comments or questions?
Thank you for taking the time to complete this questionnaire. I look forward to meeting with you soon and working with you on your journey to holistic health.
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