New Client Intake Form - Elemental Health and Nutrition

1. Personal Details
Which practitioner are you booking with?*
Name*
First Last
Address*
Street Address City State / Province / Region Postal Code
Sex*
DOB*
Age*
Additional Information
Email Private Health Fund How did you hear about Rohan?
Phone
Mobile Home Work
Emergency Contact*
Name Phone
List*
Marital Status Number of Children
Occupation*
Current Past
General Practitioner's Name*
First Last
General Practitioner's Address
Street Address City State / Province / Region Postal Code
Other Healthcare Practitioners
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Name Phone

2. Health Assessment Questionnaire
Presenting Health Issues / Medical concerns*
What symptoms would you like to have resolved as your highest priority?*
What prescription medicines are you taking?
Please provide dose, frequency and approximate start date.
e.g. Thyroxine - 100mg - Daily - June 2016
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Name Dose Frequency Start Date
What supplements are you taking?
Please provide dose, frequency and approximate start date.
e.g. Blackmores CoQ10 - 100mg - Twice daily - June 2016
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Name Dose Frequency Start Date
Health History
Please 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.
Age Health Issue/Life Event
Do you have any known allergies?
Family's Medical History
Please 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
- Cancer
Specifics
Mental Health
Please 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 Concentration
Current 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.)
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Scale Stressor
Energy Level*
List your energy level on a scale from 1 to 10 (10 being the highest):
Sleep Patterns
Please 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)
Other

3. Lifestyle
Do you currently, or have you ever used recreational drugs?*
- Yes
- No
- Past
What types? Over what time frame?
Do you currently, or have you ever smoked?*
- Yes
- No
- Past
Details - How many? For what duration? etc.
Do you exercise?*
- Yes
- No
Details - What types? How many days per week? etc.
How often do you use pharmaceutical/over the counter drugs?
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.
Daily Water Intake
Quantity Quantity Type Tap Bottled Filtered Rain Other
Daily Coffee Intake
How many per day? Milk Type (e.g. dairy, almond) Instant Espresso Decaffeinated
Daily Tea Intake
Black Tea Qty Green Tea Qty Herbal Teas Qty Herbal Teas Types
Other Fluid Intake
Fruit Juice Qty Soft Drinks Qty Diet Drinks Qty Sports Drinks Qty
Sugar added to drinks/foods?
Do you drink alcohol?
- Yes
- No
What type of alcohol, how many, and how often?
Food Intolerances
Please 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 smoke

5. Symptomology

Your Symptoms

Please select and comment on any symptoms which you suffer or have suffered from regularly.
Use + icon on the right to include all symptoms.

Symptom	Comments

6. Upload Test Results
File
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Accepted file types: pdf, doc, docx, jpg, gif, png.

7. Consent

I 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*

Elemental Health and Nutrition - New Client Intake Form

Step 1 of 8 - Personal Details

1. Personal Details

2. Health Assessment Questionnaire

3. Lifestyle

4. Male Specific Questions

4. Female Specific Questions

5. Symptomology

6. Upload Test Results

7. Consent