HEALTH EVALUATION FORM

Strictly Confidential

Please complete this form carefully. The information provided will help us build a personalised healthcare programme for you.

Biographical Details
Date: / Referring Practitioner:
Name: / Male Female / DOB: / Age:
Marital Status: Single Partnered Married Separated Divorced Widowed / Number of Children:
Email Address:
Phone: (Home) / (Work) / (Mobile)
Mailing Address:
Current Occupation: / Past Occupations:
Please do not take any supplements for 2 meals prior to your first evaluation
Clinical
Weight (kg): / Height (cm): / Blood Pressure: / Pulse:
Chief Concerns
Please rank your current health concerns and rate their severity (on a scale of 1 – 10, 10 being most severe)
1. / Scale (1-10):
2. / Scale (1-10):
3. / Scale (1-10):
4. / Scale (1-10):
Health History
Please provide a detailed timeline of your personal health history, from childhood. Include all major traumas (physical and emotional), operations and illnesses, the age you were and what changes you experienced in your health.
Other Therapies
If you have tried therapies to help these issues in the past, what was successful and what was not?
Medications
Please list any medications you are currently taking, including self-prescribed medications such as Panadol etc.
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Supplements
Please list supplements that you currently take and include brand names.
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Name: / Length of Use: / Dose:
Health Overview
Energy
Please rate your current energy level (on a scale of 1-10, 10 being the highest energy) / Scale (1-10):
Does your energy change through the day and if so how does the scale change: / Morning / Scale (1-10):
Other: / Afternoon / Scale (1-10):
Evening / Scale (1-10):
Sleep
How is your sleep? Restful Restless Hard to get to sleep Wake often Get up during night Bad dreams
Other symptoms?
What time do you usually go to sleep? / How many hours per night?
Exercise
What kind of exercise do you do?
How often do you exercise?
For how long at a time?
Stress
Please rate your current stress level (scale of 1-10, 10 being highest) / Scale (1-10):
What is the main reason for your stress?
What steps are you taking to reduce your stress level?
Emotional
Please list any psychological or emotional issues that you are currently experiencing:
How would you describe your overall mood?

Continued on next page...

Health Overview Continued
Eyes & Ears
Do you wear glasses Contact lenses Had laser eye surgery Cataracts Glaucoma
Poor night vision Wear hearing aids Have impaired hearing Poor night vision Tinnitus
Other?
Please explain:
Sunlight
Hours of natural sunlight you receive daily outside? / Hours of sunlight you receive daily through windows?
Hours spent daily under fluorescent lights?
Urination
How are your daily urinations? 2-3 hours Too frequent Sense of urgency Too small amount
Too large amount Burning Dribbling Up several times at night
Other symptoms?
Digestion
How is your digestion? Adequate Poor Acid reflux Burp often Gas Bloating Burning/pain in stomach Pain before bowel movement Nausea before bowel movement
Other symptoms?
Bowels
Eliminations per day: One Two Three Skips days Every 2-3 days Once a week
Amount: Normal Too little Too large / Other: Lots of mucous Lots of gas Foul smell
Consistency: Easy to pass Difficult to pass Formed Too hard Falls apart in toilet Floats Soft Loose
Colour: Dark brown Light brown Black Greenish brown Whitish Blood
Other symptoms?
Women Only
Are you pregnant or breastfeeding? Yes No / Date of last menstrual period:
Are your periods regular? Yes No / Cycle Length: / Menstrual duration (days):
Have you had a hysterectomy? Yes No / How many children have you delivered?
Are you going through menopause? Yes No / What is your current form of birth control?
Had an episiotomy or a C-section? Yes No / Current or previous reproductive disorder?
Had an epidural? Yes No / Have you struggled with fertility/miscarriage? Yes No
Are you experiencing any of the following? Hot flashes Night Sweats Drop in libido Painful periods
Cramping Cysts Fibroids PMS Difficulty losing weight Insomnia
Other symptoms?
Men Only
Have you experienced a drop in muscular strength, drive or libido? Yes No
Do you have difficulty urinating or have an enlarged prostate? Yes No
If you answered yes, please explain further:
Pets
Do you have any pets? Yes No / If so, what kind and how many?
Is it allowed in all areas of the house? / On your bed? / What do you feed your pet(s)?
Do you frequently de-worm your pets? / If so how often:
Chemical Exposure
Personal Care & Household Products (please indicate products & brands)
Perfume/Cologne: / Hair Product: / Shampoo: / Cleanser:
Hand/Body Lotion: / Toothpaste: / Make-up: / Hair Dye:
Nail Polish Remover: / Deodorant: / Moisturiser: / Soap:
Shave Cream: / Conditioner: / Nail Polish: / Other:
Other chemical exposure from personal care products:
Dishwashing: / Air Freshener: / Fly Spray: / Paint:
Laundry Soap: / Glass Cleaner: / Pesticides: / Other:
All-Purpose: / Insecticides: / Fertilisers: / Other:
Toilet Cleaner: / Herbicides: / Bleach: / Other:
Other chemical exposure (from garden, work, art chemicals, etc):
Electromagnetic Exposure – How many hours per day do you spend...
Watching TV: / Computer use: / On landline phone: / On mobile phone:
Wearing a pager: / Wearing a headset: / Wearing a watch: / Wearing hearing aids:
Travelling by vehicle: / How often do you use a microwave oven?
When you sleep, is your head within 3 metres of a plug-in clock (such as on a night stand)?
Please tick any of the following that you use: Microwave oven Electric stove Gas stove Electric heater
Electric blanket Water bed Water purifier (brand: ) Shower Filter (for chlorine protection)
Dehumidifier -- Cookware Stainless steel Teflon-coated Aluminium Cast iron Glass Silicone
Body Systems
Tick the individual symptoms being experienced and indicate 1 to 5 degree of severity. 5 being very severe. / Severity
LY / I experience recurrent infections, sinusitis, post nasal drip or swollen lymph nodes... / 1 2 3 4 5
LU / I experience recurrent respiratory infections, coughs, bronchitis, pneumonia, asthma... / 1 2 3 4 5
LI / I experience bouts of diarrhoea, constipation, gas, bloating... / 1 2 3 4 5
NE / I experience irritability, nervousness, trembling, anxiety, memory problems... / 1 2 3 4 5
CI / I have cold fingers/toes, blood pressure problems, varicose veins, circulation issues... / 1 2 3 4 5
AL / I react to pollens, moulds, foods, seasonal irritants, perfumes, animal dander... / 1 2 3 4 5
TH / I have a slow metabolism, am always hungry, have low energy at specific times of day... / 1 2 3 4 5
TW / I have mood swings, problems sleeping, am always cold, have chemical imbalances... / 1 2 3 4 5
HT / I experience heart palpitations, pain in my chest, irregular heart beat... / 1 2 3 4 5
SI / I have recurrent yeast infections, frequent antibiotic use, poor diet... / 1 2 3 4 5
JT / I experience joint pain, stiffness, inflammation in my body... / 1 2 3 4 5
PA / I have diabetes, blood sugar issues, irritability, shaking if I skip a meal... / 1 2 3 4 5
SP / I experience chronic fatigue, recurring infections, get sick easily... / 1 2 3 4 5
LV / I experience high cholesterol, wake up between 2-4am, indigestion after fatty meals... / 1 2 3 4 5
SK / I have rashes, dryness or cracking, scaly patches, eczema, acne, psoriasis... / 1 2 3 4 5
GD / I struggle with impotence, libido, miscarriages, sterility... / 1 2 3 4 5
UB / I have recurring urinary tract infections, painful urination, leaking, urinary frequency... / 1 2 3 4 5
KI / I experience swelling, gout, pain in the lower back, history of kidney stones... / 1 2 3 4 5
Surgeries/Injuries
What surgeries, operations, traumas, car accidents, etc have you had?
a) Have you ever had full body anaesthesia (ie. To remove tonsils, wisdom teeth, etc)?
b) Do you have any surgical implants (breast implants, metal pins, plates, clamps etc)?
c) Have you had elective surgery (rhinoplasty, tummy tuck, liposuction, mole removal, etc)?
d) Do you have pierced ears or other body piercings?
e) Do you have any tattoos?
Scars
Please describe any scars on your body (major and minor ones)
Please indicate on the charts below all surgeries, operations, piercings, tattoos, traumas, and accidents you have had.
Note: Commonly forgotten scars for men are circumcision/vasectomy and for women episiotomy scars.

Left Right

Personal Health Goals
1. How important is your health to you on a scale of 1-10 (10 being highest)?
2. What is most important to you in a health practitioner team?
3. How much confidence do you have in your body’s ability to heal itself given the right nutrients & natural therapies?
On a scale of 1-10 (10 being high)?
4. How much confidence do you have in medical drugs, on a scale of 1-10 (1= low; 10= high confidence)?
5. What are your specific health goals? (What do you really want?)
6. How far are you willing to commit to achieve your health goals? (Please be honest)
Don’t really want to change much Willing to change some
Willing to change a reasonable amount Willing to do whatever it takes
7. How much money do you spend per month on your health?
8. How long do you want to live? (Check all that apply)
Age 60-70 only if my significant other is still alive also as long as I’m healthy
Age 70-80 as long as I have been granted it’s already enough
Age 80-90 until I complete my mission (purpose) on earth forever
Age 90-100
Age 100+
Doshas – Vata/Pitta/Kapha
Energy Imbalances - Please tick the symptoms which you are experiencing regularly...
VATA – Please indicate total # of checks ()
Worried Fainting spells, dizziness Low back pain or menstrual cramping
Weakness Fatigue, poor stamina Agitated mind, difficulty concentrating
Indecisive Generalised aches, pains Constipation, intestinal gas, bloating
Nail biting Very sensitive to cold Antsy or hyperactive behaviour
Shy, insecure Dry, sore throat, dry eyes Arthritis, stiff & painful joints
Heart palpitations Tired, yet can’t relax Losing weight, underweight
Dry, rough, flaky skin Anxious, fearful, nervous Insomnia, wake up at night
Headaches
PITTA – Please indicate total # of checks ()
Boils Argumentative, bossy Very sensitive to heat, hot flashes
Impatient Fevers, night sweats Weakness due to low blood sugar
Skin rashes Sour body odour Bad breath, bitter taste in mouth
Angry, irritable Frustrated, wilful Excessive hunger or thirst
Inflammation Hostile, destructive Disturbing, violent dreams
Flushed face Bossy, controlling Critical of self and others
Blood-shot eyes Diarrhoea, loose stools Acidity, heartburn, ulcer
Acne, rosacea
KAPHA – Please indicate total # of checks ()
Nausea Slow to comprehend Mucus & congestion in sinuses/nose
Diabetes Pale, cool, clammy skin Greedy, possessive, materialistic
Slow to react Procrastinating, lethargy Clingy, hanging onto people/ideas
Groggy all day Sluggish dull thinking Body & limbs feel heavy, swollen
High cholesterol Weight gain, obesity Very tired in morning, hard to get up
Allergies, hayfever Water retention, swelling Mucus & congestion in throat/chest
Apathetic, no ambition Depressed, sad, overly sensitive Sluggish digestion, mucus in stools
Sleeping too much
Dental Health
When was your last dental appointment and what treatments were done?
Do you have any dental concerns?
Do you currently have or have you ever had any amalgam/silver fillings?
Do either of your parents have amalgam/silver fillings?
Do you experience any of the following? Receding gums Bleeding gums Mouth ulcers
Tooth pain Bad breath
Other symptoms?
Please fill out the dental chart below to the best of your knowledge. Use the example chart as a guideline:

Toxic Burden
Smoking
Do you currently smoke? / If yes, how much? / How long have you smoked?
Do you frequently breathe second-hand smoke from others who are smoking (either at home or work)?
Alcohol
Do you drink alcohol: Daily Weekly Monthly Not at all
What do you drink and how much?
Recreational Drugs - This is strictly confidential information
Do you currently use recreational drugs? Marijuana Ecstasy Cocaine Methamphetamine
Heroin Uppers Downers
Others?
Have you used recreational drugs in the past? / If yes, what and for how long?
BACTERIA
Yellow/green discharge Fever gets worse with time
Symptoms persist longer than 10-14 days Focal area of illness (sinuses, lungs, throat, etc)
I am concerned about this group. State why ►
VIRUSES
Clear discharge Low-grade fevers/chills
Body-wide aches/fatigue History of chronic viral infection (EBV, HPV, Herpes, HIV, etc)
I am concerned about this group. State why ►
MOULD/FUNGUS
Frequent antibiotic use Fungal rashes/eczema/psoriasis/yeast infections
White, coated tongue Strong cravings for sugars and starches