April 9, 2016

Health History Form

The ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by a clinician during your consultations. Health challenges are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them will help to identify underlying causes and design a safe and effective action plan.

As you complete this form please make your own note of your answers for your records. Or for example you could take a screen shot:

  • Macbook – Press the ‘shift’, ‘cmd’ and ‘4’ keys together and then select the area to copy.
  • PC: Press ‘PrtScn’.

Please complete the whole form in one go and press submit at the bottom.

All information provided is confidential.

DD/MM/YYY

MEDICAL

Click or drag files to this area to upload. You can upload up to 20 files.
Please attach any additional health and medical history details and test reports.

FEMALE ONLY

DENTAL / ORAL HEALTH

SLEEP

MOVEMENT / PHYSICAL ACTIVITY

PSYCHOLOGICAL

In order to improve your health, how willing are you to (Rate on a scale of : 5 = very willing to 1 = not willing):

Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0
Selected Value: 0

REVIEW, CONFIRM AND SUBMIT

P.S. Here are the links if you are yet to completed the rest of your Intake Paperwork: