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Elemental Health and Nutrition - New Client Intake Form

"*" indicates required fields

Step 1 of 8 - Personal Details

12%

1. Personal Details

Name*
Phone
Mobile
Home
Work
Address*
Date of Birth*
Additional Information
Private Health Fund
List*
Marital Status
Number of Children
Occupation*
Current
Past
General Practitioner's Name*
General Practitioner's Address
Other Healthcare Practitioners
Use + icon on the right to add additional fields.
Name
Phone
 
Emergency Contact*
Name
Phone

2. Health Assessment Questionnaire

Your Symptoms
Please select any symptoms which you suffer from regularly.
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
 
Family's Medical History
Please select any conditions which family members have, or have had, and note specifics.
Please select quantity, or if they have been removed in the past
Mental Health
Please select one or more from the following in regard to your mood/emotions.
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
 
List your general stress level on a scale from 1 to 10 (10 being the highest):
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.

3. Lifestyle

Do you currently, or have you ever used recreational drugs?*
Do you currently, or have you ever smoked?*
Do you exercise?*
Daily Water Intake
Quantity
Tap
Bottled
Filtered
Rain
Other
Daily Coffee Intake
How many per day?
Instant
Espresso
Decaffeinated
Milk Type (e.g. dairy, almond)
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
Do you drink alcohol?
Food Intolerances
Please select any of the following that you are intolerant to or which bother you:

4. Male Specific Questions

Do you suffer from the inability to maintain an erection?
Do you have heaviness/hardness/pain in any of the reproductive areas?
Are you losing body hair?
With regard to your flow of urine, do you have difficulty stopping?
With regard to your flow of urine, have you noticed a diminished strength of stream?

4. Female Specific Questions

Please describe your menstrual flow:
Is the flow:
Do you suffer from premenstrual tension?
Do you suffer pain?
Are you taking anything that affects your hormones? (OCP, Mirena etc)
Test Results
Please 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
All appointments have a 24hr full fee cancellation policy which is strictly enforced.*
I am contactable by email only. I don't engage in correspondance via phone, text message, Facebook etc.*
Consultations utilize Heidi, an AI-assisted transcription service. All data is securely encrypted, stored within Australia, and accessible only to my clinician in compliance with Privacy Act requirements and ISO27001 standards. No audio recordings are stored - only real-time transcriptions which become part of your private electronic health record. You can withdraw my consent at any time.*

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.

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