Full Name

Email Address

Date of Birth

Street Address

Suburb

City

Postcode

Phone Number

Occupation

How did you hear about us? How did you hear about us? Internet Search Event / Advertising GP / Healthcare Provider Family Friend Other

Emergency Contact

Relationship To You

Have you had any medical exam test or x-rays in the last 5 years? Have you had any medical exam test or x-rays in the last 5 years? Yes No

Have you ever had any surgical operations? Have you ever had any surgical operations? Yes No

Are you currently undergoing medical treatment? Are you currently undergoing medical treatment? Yes No

Have you every had Radiation or Chemotherapy? Have you every had Radiation or Chemotherapy? Yes No

Are you allergic to any foods or environmental substances? Are you allergic to any foods or environmental substances? Yes No

Are you currently taking any prescribed medication? Are you currently taking any prescribed medication? Yes No

Are you currently taking any natural supplements? Are you currently taking any natural supplements? Yes No

Do you, or have you ever used recreational drugs? Do you, or have you ever used recreational drugs? Yes No

Have you ever been vaccinated? Have you ever been vaccinated? Yes No

Do you have regular flu shots? Do you have regular flu shots? Yes No

Have you experienced any adverse reactions to vaccines? Have you experienced any adverse reactions to vaccines? Yes No

Please list your current and former occupations and pastimes

Do you, or have you ever smoked cigarettes/cigars? Do you, or have you ever smoked cigarettes/cigars? Yes No

Do you, or have you ever drunk alcohol? Do you, or have you ever drunk alcohol? Yes No

Have you ever worked with chemicals including garden sprays? Have you ever worked with chemicals including garden sprays? Yes No

Do you have any of the following? Do you have any of the following? Cancer/Tumors Cysts Eye Disease / Disorders Asthma/Lung Complaints Liver Disease/Hepatitis A,B or C Diabetes 1 or 2 Stomach Complaints (e.g. reflux, bloating, pain) Ulcers Gallstones Bladder/Urinary Disease Kidney Disease Thyroid Disease Hernia Appendicitis Rheumatic Fever Bowel/Intestinal Disease Skin Conditions Arthritis/Rheumatism Gout Snoring Night Sweats Anaemia Anxiety/Depression Glandular Fever Persistent or Frequent Colds/Flu Chronic Fatigue Varicose Veins Cramps/Twitches Cardiovascular Conditions (Chest pain, high blood pressure) HIV/AIDS Malaria Food Poisoning Parasitic Infections Cold Sores Thrush Candida Shingles Warts Epilepsy Headaches Difficulty Sleeping Back/Neck Problems Major Head Injury/Car Accident Sexually Transmitted Diseases None of the above

Please Enter any other conditions you have/have had in the past.

Is there a family history of any conditions? Is there a family history of any conditions? Yes No

Have you ever had dental or oral health issues? Have you ever had dental or oral health issues? Yes No

Do you grind/clench your teeth? Do you grind/clench your teeth? Yes No

FEMALE ONLY: Are you currently pregnant? FEMALE ONLY: Are you currently pregnant? Yes No

FEMALE ONLY: Have you been pregnant before? FEMALE ONLY: Have you been pregnant before? Yes No

FEMALE ONLY: Have you had abnormal periods? FEMALE ONLY: Have you had abnormal periods? Yes No

FEMALE ONLY: Have you had a miscarriage/abortion in the past? FEMALE ONLY: Have you had a miscarriage/abortion in the past? Yes No

FEMALE ONLY: At what age did you first menstruate?

FEMALE ONLY: Have you experienced any menstrual problems during puberty? FEMALE ONLY: Have you experienced any menstrual problems during puberty? Yes No

FEMALE ONLY: Are you currently on contraceptives? FEMALE ONLY: Are you currently on contraceptives? Yes No

FEMALE ONLY: Have you ever been on contraceptives? FEMALE ONLY: Have you ever been on contraceptives? Yes No

FEMALE ONLY: Have you ever been on Hormone Replacement Therapy (HRT)? FEMALE ONLY: Have you ever been on Hormone Replacement Therapy (HRT)? Yes No

FEMALE ONLY: Have you ever had symptoms from contraceptives or HRT? FEMALE ONLY: Have you ever had symptoms from contraceptives or HRT? Yes No

MALE ONLY: Have you ever had a vasectomy? MALE ONLY: Have you ever had a vasectomy? Yes No

MALE ONLY: Have you ever had any prostate issues? MALE ONLY: Have you ever had any prostate issues? Yes No

MALE ONLY: Have you ever experienced erectile dysfunction? MALE ONLY: Have you ever experienced erectile dysfunction? Yes No

How often do you pass stools?

times per: times per:DayWeek

Do you have diarrhoea often? Do you have diarrhoea often? Yes No

Do you have, or have you had, piles or haemorrhoids? Do you have, or have you had, piles or haemorrhoids? Yes No

Do certain foods affect your bowel motions? Do certain foods affect your bowel motions? Yes No

Do you get anal itch? Do you get anal itch? Yes No

Do you get rectal bleeding? Do you get rectal bleeding? Yes No

Have you had recent unexplained weight change? Have you had recent unexplained weight change? Yes No

What colour is your stool normally? What colour is your stool normally? Brown/Light Brown Light Yellow Green White/Clay Black

Do you experience difficulty urinating? Do you experience difficulty urinating? Yes No

Do you experience problems with frequency/urgency of urinating? Do you experience problems with frequency/urgency of urinating? Yes No

What colour is your urine normally? What colour is your urine normally? Clear/Pale Yellow Yellow Dark Yellow Pink/Red Brown/Orange Foaming/Fizzing

Do you have any problems maintaining your ideal weight? Do you have any problems maintaining your ideal weight? Yes No

Do you feel cold unduly? Do you feel cold unduly? Yes No

How would you rate your appetite? How would you rate your appetite?LowGoodExcessive

Please note down your exercise regime below (type, duration and frequency per week)

How much water do you drink daily?

Do you drink tea/coffee/fruit juices etc...? Do you drink tea/coffee/fruit juices etc...? Yes No

Do you drink tap water? Do you drink tap water? Yes No

Please list any foods you may have intolerance to:

Please list any foods you actively avoid:

Please list any foods you crave:

What foods do you eat for Breakfast?

What foods do you eat for Lunch?

What foods do you eat for Dinner?

What foods do you eat for Snacks?

Number