Let’s work together

CASE HISTORY FORM

Rest assured, all provided information will be treated with the utmost confidentiality.

Today's Date

Kindly allocate some time to complete this questionnaire, as it will enable us to optimize our sessions togethe

Name

First Name

Last Name

Date of Birth

dd/mm/yy

Phone

(###)

###

####

Gender

Maritial status

Children

Occupation

Are you happy and satisfied in your work?

Height

Weight

How would you rate your level of physical activity?

How many hours sleep do you get on average, per night?

Do you sleep well?

Do you smoke? If so, how much? If you have given up, when was that?

Do you drink alcohol? If so, how many alcoholic units do you drink per week and how many days do you drink alcohol, on average?

AIMS and GOALS

What are your top symptoms (physical or mental) that you would like to address today?

Are there any other goals you hope to achieve through our work together?

Lastly how is your general feeling of wellbeing during the past few weeks?

YOUR HEALTH STATUS

Medical Background: Please provide copies of test results that may be relevant to the consultation eg. GP blood test, stool test, parasitology, ultrasound or scan results.

Are you currently following a medically prescribed diet? If yes, pls describe

Are you currently undergoing any medical treatment?

Are you aware of any personal dental health issues?

Are you currently undergoing any alternative medicine treatments, eg, acupuncture, reflexology?

Are you planning to become pregnant within the next year?

How would you describe your mood and energy levels on an average day?

MEDICATIONS & SUPPLEMENTS

Please list below any prescribed medications – currently taking or significant past use. (significant past use refers to long term, repeated or high dose use) e.g. antibiotics, anti-depressants, anti-inflammatories, blood pressure/blood thinning medications, inhalers, medicated creams

Medication / Dose / Condition being treated / Frequency / Duration / Past (date when stopped) / Current (date when started):

Please list below any supplements that you are CURRENTLY taking – (indicate past supplement use too & specify when approximately) e.g. vitamins, minerals, herbs, fish oils, protein powder, concentrated food extracts, joint support, etc.

Supplement / Brand / Dose / Reason for taking / Frequency / Duration (if past, date when stopped, if current, date / When

Do you feel that you have taken significant amounts of prescribed medication over your lifetime - eg. antibiotics/ NSAIDS, painkillers, oral contraceptives etc?

FAMILY HISTORY

Please note down any major diseases in your biological family including which family member on either paternal or maternal side & roughly when, such as cancer, CVD, stroke, autoimmune disease, diabetes, asthma and/or hay fever, mental health issues, osteoporosis, history of eating disorder, neurodegenerative disease such as Alzheimers.

YOUR HEALTH HISTORY