Let Food be thy Medicine, and Medicine be thy Food
- Hippocrates, The Father of Medicine
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CONTACT AND HEALTH HISTORY
Childhood Health Issues.
Please tick those that applied to your situation.
Were you Breastfed?
Were you Bottle Fed?
Normal Birth?
Caesarean Section Birth?
Complications at Birth?
General Health Questions.
Please tick those that applied to your situation.
Contact Information
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General Health Information
Blood Type
Current Health Concerns
Current Infection
Mental Health Issues
Inflammation
Auto-Immune Issues
Food Issues eg. Allergies, Intolerances
Weight Issues
Skin, Hair, Nails Issue
Cancer
Heart Disease
High Cholesterol
Diabetes, Type 1 or 2
Fungal Overgrowth, eg. Candida
Migraines or Persistent Headaches
Hayfever
Exposure to Toxins
Hormone Replacement Therapy
Anti- Psychotics
NSAIDS (Anti-Inflammatory drugs)
Beta Blockers (Blood Pressure)
Blood Pressure Medication
Statins (Cholesterol Lowering)
Are you currently taking any medication?
Anti-Depressants (SSRI's)
Steroids (eg. Prednisone, Cortisol, etc.
PPI's (Stomach Acid Inhibitors) eg. Losec
Anti-Histamines (For Allergies)
Immune Suppressants eg. Autoimmunity
Anti-Fungal Medication eg. Nystatin
Antibiotics
Anti-Retro Viral Drug (eg. Acyclovar)
Anti-Malarial Treatment
Pain Medication eg. Morphine
Chemotherapy Drugs
Thyroxin for Hypothyroid
Diuretics for Kidney Function
Birth Control Pills
Hormone Dysfunction
Arthritis
Osteoporosis
Skin Infections
Genetic Disease
Eye Problems
Memory Loss, Cognitive function
Digestive Problems
Hearing Problems
Gout
Neurodegenerative Disease
Nervous System Disorder
Liver Disease eg. Fatty Liver
Gallbladder Problems
Eczema or Dermatitis
Acne or Pimples
Chronic Fatigue
Asthma
Sinusitis or Post Nasal drip
Back Pain
Sexual Dysfunction
Sleeping Problems
Dental Problems eg. cavities
What other Health Activities do you do?
Gym Regularly
Yoga
Chiropractic/Osteopathic Treatment
Massage Therapy
Cycling
CrossFit / Weight Training
Walking/Hiking
Running
Swimming
Vitamin K
Vitamin D
Omega 3's
Magnesium
Zinc
Iron
Vitamin B12
Multi B Vitamin
Multivitamin
What Operations have you had?
Vitamin C
Turmeric
DIM
Calcium
Boron
MSM (Sulphur)
Vitamin E
Evening Primrose Oil
Other Herbs
What Supplements do you Currently Take?
Prostatectomy
Hysterectomy
Bones reset, eg. accident, injury
Ceasarian Section
Gallbladder Removed
Traumatic Injury
Heart Surgery
Stomach Stapling/Band/Bypass
Abdominal Surgery
Laporoscopic abdominal procedure
Wisdom Teeth Removal
Mastectomy
Biopsy
Tonsillectomy
Back Surgery
Tumor Removal
Melanoma Removal
Appendectomy
Ear Surgery eg. Grommits, Infection, Hearing Loss
Eye Surgery, eg. Cataracts, Laser Surgery, Squint, Strabismus, Damage
Plastic Surgery or Reconstructive Surgery
Childhood Health Issues.
Please tick those that applied to your situation.
Asthma
Allergies
Hayfever
Recurrent Tonsillitis
Ear Infections
Speech Problems
Digestive Problems
GERD
Eczema
Psorriasis
Frequent Infections
Eye Problems
Failure to Thrive
Colic