Questionnaire

NEW PATIENT HISTORY FORM

Please complete the following form as thoroughly as possible prior to your visit.

Full Name

Best email address

Phone Number

Address

City

Date of Birth

Age

How did you hear about Inspired Natural Medicine?

Occupation

Number of Children

Height

Weight

What is your most important health concern?

Do you have any diagnosed medical conditions?

List any operations or traumas (physical or emotional) you have had in the past.

Current medications/supplements: (please list and include dosage and reason for taking)

Have you had any recent blood tests? (if yes, please email these to Simone before consultation)

Yes

What areas of your health do you wish to improve in order of priority?

MEDICAL HISTORY Please tick the corresponding box if you experience any of the following. As you can currently only select 1 option please add any additional ones here:

How often do you move your bowels?

MALE REPRODUCTIVE SYSTEM

Erectile dysfunction

Prostate problems

STI's

If you are currently doing exercise, please type what you are doing and how often:

When was your last course of antibiotics?

Do you drink alcohol?

Yes

Where you an active child?

Yes

Where you an overweight child?

Yes

How committed and motivated are you to making changes to improve your health?

Average

Very

Extremely

Do you skip meals?

Yes

Do you cook food at home?

Yes

Do you feel like you have enough cooking skills/knowledge?

Yes

How often do you get take-away meals per week?

24 HOUR FOOD RECALL - please record what you have eaten (and time) for the past 24hrs, please provide as much detail and be as honest as possible)

Thankyou for taking the time to complete the questionnaire. Please enter any further information you think Simone should know.

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Confidential Initial Consult Questionnaire

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