YourHealth Manly Pty Ltd
15 South Steyne, Manly NSW 2095, Australia
Ph: 02 9977 7888 Fax: 02 9977 3436
www.yourhealth.com.au
Please complete the following questionnaire. Your response remains confidential and will provide information for your practitioner to use in your assessment and treatment.
Surname: / Title: Mr / Mrs / Ms / MissFirst Name: / Date of Birth:
Gender: FEMALE / MALE / Marital Status: / Profession:
Home Address:
Suburb/Town: / State/Postcode:
Home: ( ) / Work: ( ) / Mobile:
Email Address: / Ref No/Expiry Date:
Medicare Number:
Next of Kin Name: / Relationship: / Contact Number:
How did you hear about YourHealth?
Advertisement □ Article □ Brochure/Flyer/Poster □ Direct Mail □ Email Newsletter □
Expo/Conference □ Friend/Relative/Colleague □ Gift Voucher/Prize □ Orion Corporate Health □
Pharmacy/Health Food Store □ Practitioner Referral □ Seminar □ TV/Radio Interview □
Walk-by/Signage □ Website □
YourHealth Manly Pty Ltd
15 South Steyne, Manly NSW 2095, Australia
Ph: 02 9977 7888 Fax: 02 9977 3436
www.yourhealth.com.au
General Acknowledgement and Consent Form
I, ______
of ______
understand that some of the diagnostic tests, treatments and products administered by practitioners at YourHealth Manly may be outside the parameters of conventional medicine in Australia. They fall into the category of Natural or Complementary Medicine. I understand that these diagnostic tests, treatments and products are supported by empirical knowledge, are safe, are widely and successfully used by Integrative Medical Practitioners in centres in Australia and overseas, and are only prescribed with utmost care. Some diagnostic tests and treatments offered at YourHealth centres are not covered by Medicare or private health insurance funds. All YourHealth practitioners are members and active participants of their respective professional Colleges and Associations.
I am attending YourHealth Manly of my own free will and consent and exercise my right to discuss and choose any useful and suitable treatment(s) made available to me. I understand that YourHealth practitioners may recommend and dispense items that are yet to be regulated by the Therapeutics Goods Administration (TGA), should the practitioner deem that such products or treatments are in my best interest. If there are any risks associated with using unregulated products or treatments, the YourHealth practitioner(s) will make me fully aware of these risks and provide me with sufficient information to make an informed decision.
Signed,
Patient’s Name: Witness’ Name:
______
Signature: Signature:
______
Date: Date:
______
Thank you for completing this form. It is designed to improve my understanding of your condition. DATE: __ / __ / ____
NAME: ______SEX: F □ M □
ADDRESS: ______PHONE: ______
AGE GROUP (in years): 10 – 20 □, 21 – 35 □, 26 – 50 □, 51 – 65 □, + 66 □
Is your condition affected by the weather? Are you BETTER or WORSE in:
DAMP/RAINY weather □ □
DRY weather □ □
COOL/COLD weather □ □
WARM/HOT weather □ □
a COOL CHANGE □ □
before a THUNDERSTORM □ □
in WINDY weather □ □
Is your condition affected by physical activity? Are you BETTER or WORSE with:
GENTLE MOTION □ □
STRONG EXERTION □ □
DOING MENTAL TASKS □ □
REST (SITTING) □ □
STANDING □ □
LYING ON YOUR BACK □ □
Are you worse at certain times of day? Are you BETTER or WORSE:
AFTER SLEEP □ □
in the MORNING □ □
in the AFTERNOON □ □
in the EVENING □ □
at NIGHT □ □
Do you suffer much with any of the following problems:
CONSTIPATION □, LOOSE STOOLS □, a BLOATED STOMACH □, WINDY BOWELS □, VOMITING or NAUSEA □, ABDOMINAL PAINS □, FREQUENT BURPING □, INDIGESTION □, SINUSITIS □, BLOCKED NOSE □, AN IRRITATING COUGH □, DRY MOUTH or THROAT □, FLUSHED FACE □, BREATHLESSNESS □, RED or SORE EYES □, PAINFUL JOINTS □, SWOLLEN JOINTS □, BACKACHE □, BACK STIFFNESS □, NECKACHE □, NECK STIFFNESS □, HEADACHE (Specific sites): FOREHEAD □, TOP OF HEAD □, SIDE OF HEAD □, BACK OF HEAD □,
FATIGUE □, MUSCLE WEAKNESS □, SKIN RASHES □, ITCHING SKIN □, ITCHY SCALP □, RAPID WEIGHT LOSS □, or WEIGHT GAIN □?
(For YOUNGER WOMEN) Are you affected by MENSTRATION? Are you BETTER or WORSE:
BEFORE □ □
DURING □ □
AFTER □ □
Are your PERIODS: IRREGULAR (TOO FREQUENT □, or DELAYED □), TOO HEAVY □ or LIGHT □?
Are you taking any PRESCRIBED MEDICATIONS Yes □
CONTRACEPTIVE or HORMONAL PRODUCTS Yes □
VITAMINS or MINERALS Yes □
HERBAL MEDICINES? Yes □
If YES, please detail NAMES (& DOSES):______
______
Have you ever had any SEVERE INFECTIONS Yes □
SERIOUS OPERATIONS Yes □
SERIOUS ILLNESSES Yes □
If YES, please outline (including dates): ______
Have you had any BAD VACCINATION REACTIONS? Yes □
If YES, do you know which vaccine? : POLIO □, TETANUS-DIPTHERIA-PETUSSIS (TRIPLE ANTIGEN) □, T.B. □, SMALL POX □, YELLOW FEVER □, MEASLES-MUMPS-RUBELLA □, MENINGITIS □, HAEMOPHILUS (HIB) □, HEPITITUS A □, HEPATITUS B □, CHICKEN POX □.
Have you noticed any?
INCREASED HUNGER □, LOSS OF APPETITE □, INCREASED THIRST □, LACK OF THIRST □,
INCREASED or ALTERED TASTE □, or LOSS OF SENSE OF TASTE □ ?
(Do things taste rather BITTER □, SWEET □, FOUL □, METALLIC □ ?)
INCREASED SENSE OF SMELL □, or a LOSS of your usual SENSE OF SMELL □?
DETERIORATION in your HEARING □, or your VISION □?
SWEATING: FOR NO REASON □, MAINLY IN THE AFTERNOON □, MORE AT NIGHT □?
FEVERISHNESS: FOR NO REASON □, MAINLY IN THE AFTERNOON □, MORE AT NIGHT □?
Is there any associated:
ANXIETY: Due to events beyond your control □, or Does the ANXIETY seem to come from within yourself □?
With FEELINGS of: FEAR or TERROR □, GRIEF □, SHOCK □ or ANGER □?
FAINTNESS □, VERTIGO or DIZZINESS □, POOR MEMORY □, POOR CONCENTRATION □,
MENTAL CONFUSION □, INTENSE DREAMING □, SADNESS □, or DEPRESSION □?
IRRITABILITY □, or RESTLESSNESS □, HEART PALPITATIONS □, INSOMNIA □?
WAKING IN THE EARLY HOURS □, POOR BALANCE □, UNUSUAL CLUMSINESS □,
TWITCHING or TREMORS □, NOISE in your EARS (TINNITUS) □, TOOTHACHE □,
FREQUENT PASSING of a DILUTE URINE □, or INFREQUENT PASSING of a STRONG URINE □?
WEAK SEX DRIVE □, or rather an unusually HIGH SEX DRIVE □?
Do your PALMS & the SOLES (of your feet) often have a feeling of: NUMBNESS □, HEAT □, or COLDNESS □?
Does your SKIN have frequent sensations of: “PINS & NEEDLES” □, STINGING □, or CRAWLING □?
Is there any sensation in your CHEST of: PAIN □, OPPRESSION or HEAVINESS □, or FULLNESS □?
Presently do you generally feel BETTER or WORSE: BETTER or WORSE:
If you are TOUCHED LIGHTLY □ □
If you are PRESSED FIRMLY □ □
If you are IN YOUR OWN COMPANY □ □
If OTHERS ARE AROUND □ □
If you are INDOORS □ □
If you are OUT IN THE OPEN AIR □ □
If you are AT THE BEACH □ □
If you are IN A DRAUGHT □ □
WITH A FAN ON □ □
OUT IN THE WIND □ □
WRAPPING UP WARMLY □ □
UNCOVERING A LITTLE □ □
WHILE YOU ARE EATING □ □
AFTER EATING □ □
Do you have a preference for: WARM DRINKS □, WARM FOODS □, COLD DRINKS □, COLD FOODS □?
Do you have any particular: FOOD CRAVINGS: ( SWEET □, SALTY □, BLAND □, SPICY □ ),
or DRINK CRAVINGS: ( HOT □, COFFEE □, TEA □, COLD □, COLA □, SWEET □ )
Are you upset by: ALCOHOL □, DAIRY □, EGG □, NUTS □, MEAT □, SEAFOOD □, SPICES □, FATS □, ONION □?
Are you sensitive to: LOUD NOISES □, STRONG SMELLS □, or BRIGHT LIGHTS □?
Is there any unusual BRUISING OF THE SKIN □, or BLEEDING from the SKIN, NOSE, BOWEL or BLADDER □?
Do your WAIST & HIPS often feel WEAK and SORE: Yes □? Do you often have SWOLLEN ANKLES: Yes □?
Do you suffer with ALLERGIES: Yes □? Can you be specific?:______
Thank you for completing this form. It is designed to improve my understanding of your child’s condition. DATE: __ / __ / ____
CHILD’S NAME: ______SEX: F □ M □
AGE: ______YEARS ______MONTHS ______WEEKS
PARENT’S NAMES: ______
CONTACT ADDRESS: ______PHONE: ______
PRE-CONCEPTION: Were there any serious health problems in either parent at the time of the child’s conception? __
______
PREGNANCY: Any health problems during the pregnancy? ______
BIRTH: Did the birth go smoothly? (i) YES ___, (ii) YES except for ______
(iii) NO ______
VACCINATION: Is your child vaccinated? (i) YES ____, NO _____
If YES, were there any problems following vaccination? NO _____, YES following ______
FEEDING: Did your child have any difficulties with cow’s milk? YES ____, NO _____.
Was a special formula necessary? YES ____ (Type:______), NO ____.
Did your baby suffer much from colic ____ or wind ____? Has your child lost weight ____?
Is your child always hungry ____, or have they become hungrier recently ____?
Do you have a thirsty child ____, or do they seem to drink less than normal ____?
Does your child have a problem with the following foods: milk ____, rich food ____, ice-cream ____, eggs ____, meat ____, sweets ____, salty food ____, fish ____, fruit ____, other ______?
Does your child crave: egg yolk ____, or food that is sweet ____, salty ____, or spicy ____?
Drinks that are cold ____, or hot ____? Will they only eat blandly-flavoured foods ____?
TEETHING: Were there major problems with teething ____? Have the teeth come down a little crooked ____,
or have one or two decayed ____, or been easily broken ____?
BOWELS: Have the bowels been a problem ____? Has there commonly been constipation ____, diahorrea ____, soft pale motions _____, a foul odour ____, pain on passing ____?
Does your child suffer with a smelly flatulence ____ or stomach cramps ____?
Was toilet-training difficult to achieve? YES ____ NO ____
GENERAL: Does your child seem to have plenty of energy ____, or do they tire easily ____?
Are they a hot-blooded child ____, or a little chilly and cold sensitive ____?
Do they react fairly slowly ____, or do they usually do things (too) quickly ____?
Are they easily discouraged when thwarted ____, or are they persistent ____?
Is your child rather more obstinate than usual at present ____?
Have they been hurtful to their toys/pets/siblings recently ____?
Have they been somewhat indifferent to the family members around them ____?
Does your child seem forgetful ____, and has this been worse recently ____?
Have they become more irritable ____, or restless ____ in recent times?
Do they cry in the presence of strangers ____, or are they shy and quiet ____?
When upset, is your child easily comforted when being held ____, or do they get worse ____?
Are they presently touchy and easily upset ____? Are they often like this ____?
Has there been an excessive amount of jealously ____ or greediness _____ recently?
Has your child been asking for things then refusing them when offered ____?
Has your child become rather more impatient than usual ____?
Have they become more insolent ____, rude ____, or abusive ____ in behaviour?
Has your child become more critical of you in recent times ____?
Do they dislike having much clothing on ____? Are they always loosening their clothes ____?
Does your child become anxious at times without any apparent cause ____?
Are they afraid of the dark ____? Must they have a light on at night ____?
Do they become a little anxious at around sunset ____?
Is your child prone to: fainting ____, or dizziness ____, moodiness ____, sleeplessness in the evening____,
slowness to go to sleep ____, episodes of depression ____, or prolonged periods of sadness ____?
Are they easily startled by noises when awake ____, or asleep ____?
HEAD: Does headache occur from time to time ____? Does hunger bring on headache ____?
Do headaches come on when your child is concentrating on something ____?
Does your child quickly get red around the face when exerting himself ____?
Is your child prone to sweating easily on effort ____, sweating at night ____, around the head ____,
on the face ____, on uncovered areas ____?
Are they prone to dandruff or itching of their scalp ____, rashes behind their ears ____,
swollen glands around the head or neck ____, a clear runny nose ____, a yellow/green runny nose ____, a blocked nose ____, nosebleeds ____, hay fever ____,
scabs around the nose ____, bouts of sneezing ____, cold sores ____, mouth ulcers ____,
styes ____, ear ____ or eye infections ____?
Do they suffer much with tonsils ____, adenoids ____, pharyngitis ____, croup ____, sore throat ___?
Do the lips crack or split easily ____?
CHEST: Is there a proneness for chest infection ____ or cough ____?
If YES, has asthma been suspected ___ or confirmed ____? Is there a family history of asthma ____?
Is their cough worse in damp conditions ____? Is your child easily upset by tobacco smoke ____?
Does cold weather bring on a cough ____, or is hot weather more troublesome ____?
WEIGHT: Is your child overweight ____, normal size ____, or a bit undersize for age ____?
Have they been this way for a while ____, or has there been a rapid change ____>
WEATHER: Does the weather seem to affect your child? Are they BETTER (B) or WORSE (W) in:
DAMP ____ or RAINY weather ____, DRY weather ____, or COLD weather ____,
HOT weather ____, during COOL CHANGES ____, during WARM CHANGES ____,
before THUNDERSTORMS ____, during THUNDERSTORMS ____?
TIME: Are they BETTER (B) or WORSE (W) at certain times of day?
AFTER SLEEP ____, in the MORNING ____, around NOON ____, AFTERNOON ____,
at SUNSET ____, in the EVENING ____, at NIGHT ____?
Is there a predictable worse time ______?
SKIN: Do they suffer much with any of the following:
OILY SKIN ____, DRY SKIN ____, SKIN RASHES ____, ITCHY SKIN ____, MOLES ____,
BOILS ____, THRUSH ____, RINGWORM ____, or FUNGAL infections ____?