Elemental Health and Nutrition - New Client Intake Form"*" indicates required fieldsStep 1 of 8 - Personal Details12%1. Personal DetailsName* First Last Email* PhoneMobileHomeWorkAddress* Street Address City State / Province / Region Postal Code Sex*SelectMaleFemaleDate of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Height (cm)Weight (kg)How did you hear about Rohan?*FriendFamilyFacebookGoogleDoctor referralOther practitioner referralIt came to me in a dreamAdditional InformationPrivate Health FundList*Marital StatusNumber of ChildrenOccupation*CurrentPastGeneral Practitioner's Name* First Last General Practitioner's Address Street Address City State / Province / Region Postal Code Other Healthcare PractitionersUse + icon on the right to add additional fields. NamePhone Add RemoveEmergency Contact*NamePhone2. Health Assessment QuestionnairePresenting Health Issues / Medical concerns*What symptoms would you like to have resolved as your highest priority?*Your SymptomsPlease select any symptoms which you suffer from regularly. Bloating (related to digestion) Heartburn Reflux Excessive burping Stomach pain Stool - Constipation (miss days or straining) Stool - Diarrhoea/ loose Stool - Blood or mucous Flatulence - Excessive Nausea Thrush Bladder problems - e.g. UTIs, Cystitis Waking at night to urinate Hemorrhoids, varicose veins, spider veins High blood pressure Low blood pressure High cholesterol High blood sugar Anaemia Cold hands and feet Feel fluidy or swollen Dizziness Migraines Headaches Asthma Hayfever/ sinus problems Respiratory problems Viruses - e.g. herpes, glandular fever Colds, flus, coughs more than twice eer year Skin - acne/ eczema, psoriasis, tine etc Infertility Low libido Hair loss Forgetful/ vague Muscle cramps or aches Back painWhat prescription medicines are you taking?Please provide dose, frequency and approximate start date.e.g. Thyroxine - 100mg - Daily - June 2016Use + icon on the right to add additional fields. NameDoseFrequencyStart Date Add RemoveWhat supplements are you taking?Please provide dose, frequency and approximate start date. e.g. Blackmores CoQ10 - 100mg - Twice daily - June 2016 Use + icon on the right to add additional fields. NameDoseFrequencyStart Date Add RemoveHealth HistoryPlease give a brief description of your health, including any diagnosis/conditions/injuries/major events or traumas, starting from your younger years to the present. Use + icon on the right to add additional fields. e.g: 21 | Appendix removed.AgeHealth Issue/Life Event Add RemoveDo you have any known allergies?Family's Medical HistoryPlease select any conditions which family members have, or have had, and note specifics. Heart disease Diabetes Addictions Parkinson's Osteoporosis Obesity Hypothyroid Hormonal Issues Allergies Skin Problems Depression/Anxiety High blood pressure Autoimmune conditions Respiratory issues Blood disorders Bowel disorders Celiac disease Pregnancy conditions Renal issues Alzheimers disease/ Dementia CancerSpecificsPlease list all scars you have (including from childbirth or laparoscopy procedures etc.)Do you have any amalgam teeth fillings?Please select quantity, or if they have been removed in the past0Been removed123456789>10Mental HealthPlease select one or more from the following in regard to your mood/emotions. Depression Anxiety Panic Hyperactive Manic Agitated Restless Continual Worrying Tendency to 'blow up' Moody (highs and lows) Impulsive Addictive Tendencies Obsessive Compulsive High Achiever Perfectionist Nervousness Sensitive Lack of Motivation Poor ConcentrationCurrent Stressors*List your top current stresses, and rate them on a scale from 1 to 10 (10 being the most stressful): (e.g. Work, Relationships, Time poor, Financial Stress, Health, etc.) Use + icon on the right to add additional fields. ScaleStressor Add RemoveTotal Stress Level*List your general stress level on a scale from 1 to 10 (10 being the highest):12345678910Energy Level*List your energy level on a scale from 1 to 10 (10 being the highest):12345678910Sleep PatternsPlease select one or more from the following in regard to your sleep patterns. Great Hypersomnia Insomnia Daytime napping Waking once asleep Can't remember dreams Vivid dreams Snoring Mouth breathing Teeth grinding Restless legs Sleep talking Unrefreshed on waking Waking to urinate Delayed onset (can't fall asleep before midnight) Sleep apneaOther3. LifestyleDo you currently, or have you ever used recreational drugs?* Yes No PastWhat types? Over what time frame?How often do you use pharmaceutical/over the counter drugs?Do you currently, or have you ever smoked?* Yes No PastDetails - How many? For what duration? etc.Do you exercise?* Yes NoDetails - What types? How many days per week? etc.Do you have any issues inhibiting your ability to exercise? Please elaborate.What do you do for relaxation and how often?Have there been any recent changes (work, relationship, house move, etc.)? Please elaborate.Have you experienced any trauma or loss?Daily Water IntakeQuantityTapBottledFilteredRainOtherDaily Coffee IntakeHow many per day?InstantEspressoDecaffeinatedMilk Type (e.g. dairy, almond)Daily Tea IntakeBlack Tea QtyGreen Tea QtyHerbal Teas QtyHerbal Teas TypesSugar added to drinks/foods?Other Fluid IntakeFruit Juice QtySoft Drinks QtyDiet Drinks QtySports Drinks QtyDo you follow any particular dietary regime (FODMAPS, Paleo, Vegan, Keto etc.)Do you drink alcohol? Yes NoWhat type of alcohol, how many, and how often?Food IntolerancesPlease select any of the following that you are intolerant to or which bother you: Dried fruit Onions Garlic Eggs Wine Chocolate Cheese Dairy Tomatoes Capsicum Fish Bread/Pasta Gluten Nuts Citrus Preservatives Amines Histamines Salicylates Additives Perfume Chemicals Cigarette smoke4. Male Specific QuestionsDo you suffer from the inability to maintain an erection? Yes NoDo you have heaviness/hardness/pain in any of the reproductive areas? Yes NoAre you losing body hair? Yes NoWith regard to your flow of urine, do you have difficulty stopping? Yes NoWith regard to your flow of urine, have you noticed a diminished strength of stream? Yes No4. Female Specific QuestionsPlease describe your menstrual flow: Absent Menstrual Perimenopausal MenopausalIs the flow: Normal Heavy LightHow many days does your flow last?How many days between cycles?Not applicable13-1920-2728-2930-35IrregularDo you suffer from premenstrual tension? Yes NoDo you suffer pain? Yes NoDetails - (e.g. tender breasts, back pain, migraines)Are you taking anything that affects your hormones? (OCP, Mirena etc) Yes NoDetails - (e.g. Implanon, Dianne, Progesterone)How many times have you been pregnant?Other commentsTest ResultsPlease email copies of any blood work or functional testing to rohan@elementalhealthandnutrition.com.au. If you have a large number of documents please convert them to a pdf file before uploading, using this easy to use converter - www.online2pdf.com No problems, I'll send them through I don't have any results to shareAll appointments have a 24hr full fee cancellation policy which is strictly enforced.* Yes, i understandI am contactable by email only. I don't engage in correspondance via phone, text message, Facebook etc.* Yes, i understand7. ConsentI hereby agree and understand that the treatment/advice given will include one or more of the following: dietary prescription, lifestyle prescription, nutritional/herbal supplements and screening tests, which I knowingly and willingly consent to undergo of my own free will. At any time I may reject any treatment or advice without prejudice from the practitioner. I understand that nutritional/herbal supplements are prescribed in a therapeutic fashion and if circumstances change (e.g. pregnancy, cessation/commencement of pharmaceutical drugs etc) from what was presented to the practitioner, I will notify the practitioner immediately, so treatment/advice can alter accordingly if required. I understand that contact details may be used to enable correspondence via email.Signature*Date* DD slash MM slash YYYY
