Health Assessment Form

These forms can take between 5 – 15 minutes to complete. Please ensure that you have sufficient time to do this in one sitting, as it is not possible to save your form until you have completed all the entries.

New Client Intake

Page 1
Section 7
Female Only
Male Only
Health Complaints
Family History
Food Diary
sleep
Mould Screening
History

0% Complete

1 of 10

Name *

First

Last *

Last

Email *

Phone number

Address

Date of birth *

Age *

Gender *

Occupation

Blood Pressure

Pulse

Blood Type

Group 1

(please indicate the severity of your symptoms for the following N/A not applicable - mild ~ moderate ~ severe

Acid foods upset

N/A

Acid foods upset

N/A

Frequently get chilled

N/A

Lump in throat

N/A

Dry mouth-eyes-nose

N/A

Pulse speeds up after meals

N/A

Feeling keyed up/difficulty calming

N/A

Cuts heal slowly

N/A

Gag easily

N/A

Unable to relax/easily startled

N/A

Extremities cold/clammy

N/A

Irritated by strong light

N/A

Reduced amount of urine

N/A

Heart pounds after retiring to bed

N/A

Nervous stomach

N/A

Frequent cold sweats

N/A

Fever easily raised

N/A

Neuralgia-like pains

N/A

Staring with infrequent blinking

N/A

Group 1 Total Score

Group 2

please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:

Joint stiffness on rising

N/A

Muscle/leg/toe cramps at night

N/A

Butterfly stomach

N/A

Watery eyes or nose

N/A

Frequent blinking

N/A

Swollen/puffy eyelids

N/A

Indigestion soon after meals

N/A

Always seem hungry; frequently lightheaded

N/A

Rapid digestion

N/A

Frequent vomiting

N/A

Frequent hoarseness

N/A

Irregular breathing

N/A

Slow pulse/irregular

N/A

Slow gagging reflex

N/A

Difficulty swallowing

N/A

Alternating constipation and diarrhoea

N/A

Slow starter

N/A

Frequently chilled

N/A

Perspire easily

N/A

Poor circulation, sensitivity to cold

N/A

Subject to colds, asthma, bronchitis

N/A

Group 2 Total Score

Group 3

please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:

Eating when nervous

N/A

Excessive appetite

N/A

Hungry between meals

N/A

Irritable before meals

N/A

Get shaky when hungry

N/A

Fatigue which is relieved by eating

N/A

Lightheaded if meals are delayed

N/A

Heart palpitations if a meal is missed or delayed

N/A

Afternoon headaches

N/A

Overeating sweets upsets

N/A

Waking after a few hours sleep - difficulty getting back to sleep

N/A

Craving for something sweet or coffee in the afternoon

N/A

Moods of depression, blues or melancholy

N/A

Abnormal craving for sweets or snacks

N/A

Group 3 Total Score

Group 4

please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:

Hands and feet go numb readily

N/A

Frequently sighing, feeling 'air hungry'

N/A

Aware of breathing heavily

N/A

High altitude discomfort

N/A

Needing to open windows in a closed room

N/A

Susceptible to colds & fevers

N/A

Afternoon yawner

N/A

Frequently feeling drowsy

N/A

Swollen ankles, worse at night

N/A

Muscle cramps, worse during exercise; get charley horses

N/A

Shortness of breath on exertion

N/A

Dull pain in chest or radiating into left arm, worse on exertion

N/A

Bruise easily, black/blue spots

N/A

Tendency to anaemia

N/A

Frequent nose bleeds

N/A

Noises in head or ringing in ears

N/A

Tension under breastbone or feeling of tightness, worse on exertion

N/A

Group 4 Total Score

Group 5

please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:

Dizziness

N/A

Dry skin

N/A

Burning feet

N/A

Blurred vision

N/A

Itchy skin and feet

N/A

Excessive hair loss

N/A

Frequent skin rashes

N/A

Bitter or metallic taste in mouth in the mornings

N/A

Bowel movements painful or difficult

N/A

Worrier, feeling insecure

N/A

Feeling queasy; headache over the eyes

N/A

Greasy foods upset

N/A

Light-coloured stools

N/A

Peeling skin on soles of feet

N/A

Pain between the shoulder blades

N/A

Frequent use of laxatives

N/A

Stools alternating from soft to watery

N/A

History of gallbladder attacks or gallstones

N/A

Sneezing attacks

N/A

Bad dreams, nightmares

N/A

Bad breath (halitosis)

N/A

Consumption of milk products causes distress

N/A

Sensitivity to hot weather

N/A

Burning or itching anus

N/A

Craving for sweets

N/A

Group 5 Total Score

Group 6

please indicate the severity of your symptoms for the following mild ~ moderate ~ severe:

Loss of taste for meat

N/A

Lower bowel gas several hours after eating

N/A

Burning stomach sensations relieved by eating

N/A

Coated tongue

N/A

Passing large amounts of foul smelling gas

N/A

Indigestion half to one hour after eating (may be up to 3 or 4 hours)

N/A

Mucus colitis or Irritable bowel

N/A

Gas shortly after eating

N/A

Bloated stomach after eating

N/A

Group 6 Total Score

If you are human, leave this field blank.

Click here to read the Privacy Policy relating to this form

Health Assessment Form

Group 1 arrowup6

Group 2 arrowup6

Group 3 arrowup6

Group 4 arrowup6

Group 5 arrowup6

Group 6 arrowup6

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6