Health Questionnaire Please fill out the below questionnaire before your visit. Name* First Last Email* Enter Email Confirm Email Date of Birth* Address* Street Address Address Line 2 Suburb ZIP / Postal Code New ZealandAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Mobile*Home PhoneWork PhoneOccupation*Emergency ContactName* First Last Relationship*Contact Number*Main reason for your visit*Medical HistoryHave you had any medical exam test or x-rays in the last 5 years?*YesNoPlease Specify:Have you ever had any surgical operations?*YesNoPlease Specify:Are you currently undergoing medical treatment?*YesNoPlease Specify:Have you every had Radiation or Chemotherapy?*YesNoPlease Specify:Are you allergic to any foods or environmental substances?*YesNoPlease Specify:Are you currently taking any prescribed medication?*YesNoPlease SpecifyName of ProductDosage (Per Day)Start Date Are you currently taking any natural supplements?*YesNoPlease SpecifyBrandName of ProductDosage (Per Day)Start Date Do you, or have you ever used recreational drugs?*YesNoPlease SpecifyVaccinationsHave you ever been vaccinated?*YesNoWere you fully or partially vaccinated?*FullPartialDo you have regular flu shots?*YesNoHave you experienced any adverse reactions to vaccines?*YesNoOccupations Please list your current and former occupations and pastimes:Occupation(s)* Pastime(s) Do you, or have you ever smoked cigarettes/cigars?*YesNoDo you, or have you ever drunk alcohol?*YesNoHave you ever worked with chemicals including garden sprays?*YesNoPlease specifyDo 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 Please Enter any other conditions you have/have had in the past.Is there a family history of any conditions?*YesNoMother*Mothers Father*Mothers Mother*Father*Fathers Father*Fathers Mother*Siblings:*Other:Dental & Oral Health Do you have dental or oral health issues?*YesNoPlease Specify:Do you grind/clench your teeth?*YesNoFemale OnlyAre you currently pregnant?YesNoHave you been pregnant before?YesNoHave you had abnormal periods?YesNoPlease Specify: Long/Short Cycle Length Irregular/Absent Menstruation Pain/Cramping Heavy/Light Bleeding Sugar/Carb Cravings Spotting Clotting Breast Tenderness/Pain PMS Fluid Retention Have you had a miscarriage/abortion in the past?YesNoAt what age did you first menstruate?Please enter a value between 1 and 100.Have you experienced any menstrual problems during puberty?YesNoAre you currently on contraceptives?YesNoPlease Specify:Have you ever been on contraceptives?YesNoPlease Specify:Have you ever been on Hormone Replacement Therapy (HRT)?YesNoPlease Specify:Have you ever had symptoms from contraceptives or HRT?YesNoPlease Specify:MaleHave you ever had a vasectomy?YesNoHave you ever had any prostate issues?YesNoHave you ever experienced erectile dysfunction?YesNoStoolsHow often do you pass stool?*times per*DayWeekDo you have diarrhoea often?*YesNoDo you have, or have you had, piles or haemorrhoids?*YesNoDo certain foods affect your bowel motions?*YesNoDo you get anal itch?*YesNoDo you get rectal bleeding?*YesNohave you had recent unexplained weight change?*YesNoWhat colour is your stool normally?* Brown/Light Brown Light Yellow Green White/Clay Black UrineDo you experience difficulty urinating?*YesNoDo you experience problems with frequency/urgency of urinating?*YesNoWhat colour is your urine normally?* Clear/Pale Yellow Yellow Dark Yellow Pink/Red Brown/Orange Foaming/Fizzing Weight & MetabolismDo you have any problems maintaining your ideal weight?*YesNoDo you feel cold unduly?*YesNoHow would you rate your appetite*LowGoodExcessiveExercisePlease note down your exercise regime belowType of ExerciseDurationFrequency (Per Week) DietHow much water do you drink daily?**LitresGlassesDo you drink tea/coffee/fruit juices etc...?*YesNoPlease Specify:Do you drink tap water?*YesNoPlease list any foods you may have intolerance to:Please list any foods you actively avoid:Please list any foods you crave:What type of foods do you typically eat from day to day?What foods do you eat for Breakfast?*WeekdayWeekend What foods do you eat for Lunch?*WeekdayWeekend What foods do you eat for Dinner?*WeekdayWeekend What foods do you eat for Snacks?WeekdayWeekend Thank you for your time. Please note that all information provided will be strictly confidential and will not be disclosed to anyone without your permission.
