181 Willis Street, Anzac House, Wellington 6011
P 801 7520  M 021 606 844  E

Hello and welcome to Orange Health - Please complete this health profile & return to us before your appointment. It is likely to take you 20-30 minutes to complete. All information shared remains confidential. Please type your responses in the spaces. Press F11 (on keyboard) to move to each space or click in a space with your mouse. Where there are brackets ie [ ] please type an X to indicate your response. Control S to save as you go.

Personal details

Name
/
Date of birth
/
Age
Phone
/
Nationality
/
Sex
Mobile
/
Email
Address
/ Please give clear delivery details for courier ie leave @ door / no sign OK /
Postal code
Occupation
/
Name of GP
Yourweight
/
How many children?
/
Age(s)

Background

How did you hear about us?
Have you seen a naturopath or herbalist before: Yes [ ] No [ ]

Please list all therapists you currently have treatment with, ie dermatologist, osteopath, massage therapist, dietician etc.

Please list any health issues you would like to address and how long you have had them? We will go into more detail at your consultation.

1 / Office use only
Sx onset
Agg Fact
Relieving Fact
Previous tx
Underlying cx
2
3
4
5
What would be your one best outcome?

Medication

List all medication you are taking including vitamins, minerals & herbs ie:

Laxatives[ ] Antacids[ ] Acne medicationsiedoxycyclene (now or past)[ ]how many courses?

Steroids[ ] Pain killers[ ] Sleeping pills[ ] Contraceptive pill[ ] Antidepressants (now or in the past) [ ]

For how long?

Specify daily intake and dose

Medication/supplement

/

Dosage per day

/

Length of time

Client name | page 1

List any X-rays, scans or blood tests you have had in the last six months:

Family history

Please type ‘X’ in brackets if any close family has any of the following conditions:

Arthritis[ ] Heartdisease[ ] Diabetes[ ] Cancer [ ] Parkinson’s [ ] Alzheimer’s [ ] Epilepsy [ ]

Dementia[ ] Mental illness[ ] Other (specify)

general health

When was the last time you used antibiotics and what for:
How do you feel in the morning? Bright [ ] Sluggish [ ]
What worries you when you wake at night?
What operations have you had and when?
Have you had the flu vaccine or any other vaccines recently? Yes [ ] No [ ]
Have you travelled overseas recently? If so where?

Please rate the following 1 to 10 (1 = low and 10 = high):

Energy levels

/

Pain

/ Stress

Anxiety

/ Do you have panic attacks?
Yes [ ] No [ ] /

Depression

Please note if you have suffered long periods of high stress in the past. Yes [ ] No [ ]

Your health history

In sections 1-10 please indicate any conditions you have on a regular basis, or have been a problem in the past.
1Illnesses
Chemical reactions [ ] Tropical disease [ ] Chronicfatigue [ ] Rheumaticfever [ ] Cancer [ ]
Diabetes – excess thirst, excess urination, excess hunger [ ] Childhood diseases (only mention if very ill) [ ]
Psychiatricdisorders [ ] Jaundice [ ] Hepatitis [ ] Glandularfever [ ] Immunisationreactions [ ]
Tumors [ ] Cysts [ ] Appendicitis [ ] Thyroidconditions [ ] Eating disorders [ ] Alcoholism [ ]
Please note any illnesses you had as a child (eg asthma, migraines)
2Respiratory system
Asthma [ ] Lungcomplaints [ ] Grommets [ ] Earache [ ] Glueear [ ] Postnasaldrip [ ]
Sorethroat [ ] Hayfever [ ] Sinus [ ] Wheeze [ ] Chestinfections [ ] Runny nose [ ]
Constantcough [ ] Snoring [ ] Nosebleeds [ ] Recurrent colds &flus [ ] Shortness of breath[ ]
Other? Please indicate if you live near a golf course [ ] farm [ ]orchard [ ] exposed to garden sprays [ ]
hair dressing chemicals, spa pool, chemicals, fly spray [ ] plug in air fresheners or repellants [ ] painting or
renovation [ ] have air conditioning at home or work [ ] on tank water supply [ ]
live near a vodafone or telecom tower, overhead high tension wires, pylons, power transformers [ ] Do you have
a smart meter in your home [ ] Do you charge your phone by your bed [ ] Other (specify)?
3Stomach and bowel
Diahorrea [ ] Constipation [ ] Bodyodour [ ] Candida [ ] Thrush,yeastinfections [ ]
Indigestion [ ] Diverticulitis [ ] Weightchangesorissues [ ] Heartburn [ ] Reflux [ ] IBS [ ]
Bloating [ ] Stomachulcers [ ] Crohn’s [ ] Colitis [ ] Flatulence [ ] Burping [ ] Rectalbleeding [ ]
Nausea [ ] Vomiting [ ] Mouthulcers [ ] Rectalitching [ ] Hemorrhoids [ ] Badbreath [ ]
Gallstones(now or past)[ ] Do you have root canals? Yes[ ]No [ ] Other(specify)? [ ]
How many times do yourbowelsmovedaily: [ ]
4Cardiovascular / heart
Chestpain [ ] Palpitations [ ] High bloodpressure [ ] Low blood pressure [ ] Heartdisease [ ]
Angina [ ] Varicoseveins [ ] Swollenwristsorankles [ ] Shortnessofbreath [ ] Chilblains [ ]
Highcholesterol[ ] Coldhandsorfeet [ ] Sweating [ ] Other(specify)? [ ]
5Urinary system
Frequency [ ] Urgency [ ] Painonpassingurine [ ] Difficultly starting [ ] Strongcolour[ ]
Strong smell [ ] Up often at night [ ] Incontinence [ ] Kidneydiseaseorstones (now or past) [ ]
Prolapse[ ] Cystitisorkidneyinfections (now or in the past)[ ] Other (specify)? [ ]
6Nervous system
Grind teeth [ ] Dreamsornightmares [ ] Poormemory [ ] Headaches [ ] Migraines [ ]
Crampsor twitches [ ] Hearingloss [ ] Tinnitus [ ] Eyedisorders [ ] Dizziness [ ] Vertigo [ ]
Numbnessortingling [ ] Excesssweating [ ] Difficultysleeping [ ] Especiallycompetitive [ ]
Perfectionist [ ] Do you get afrighteneasily? [ ] Other (specify)? [ ]
7Muscles and bones
Achesandpains [ ] Stiffness [ ] Arthritis [ ] Rheumatoid [ ] Gout [ ] Jointpain [ ] Backproblems [ ]
If you have had a major head injury or physical trauma - please explain
8Skin
Rashes [ ] Fungal [ ] Warts [ ] Moles [ ] Coldsores [ ] Shingles [ ] Boils [ ] Bruiseeasily [ ]
Psoriasis [ ] Dermatitis [ ] Eczema [ ] Dryskin [ ] Oilyskin [ ] Slowhealing [ ] Hairloss [ ]
Weakhair [ ] Dandruff [ ] Soft,splitor peelingfingernails [ ] Acne [ ] Herpesvirus [ ] HPV [ ]
9Women only to complete
Are you pregnant? Yes[ ] No[ ] Are you trying to get pregnant? Yes [ ] No [ ]IUDfitted [ ]
Hysterectomy, if so how long ago? What form of contraception?
Menstrual flow: light [ ] heavy [ ] clotting [ ] I don’t menstruate [ ] Unusualvaginaldischarge [ ]
Menstrualcramps [ ] Cyclelengthisregular [ ] or irregular [ ] PMT [ ] Breasttenderness [ ]
Polycysticovaries [ ] Endometriosis [ ] Fibroids [ ] Sexuallytransmitteddiseases [ ]
Nightsweats [ ] Hotflushes [ ] HRTuse [ ] Hysterectomy [ ] Heartpalpitations [ ]
Painduringintercourse [ ] Fluidretention [ ] Moodswings [ ] Lowlibido [ ] Irondeficiency [ ]
Mammogram (when?) [ ] Smear (when?) [ ] Abnormalcervical smear (when)? [ ]
Bonedensity (when?) [ ] Numberofpregnancies [ ] Terminations [ ] Miscarriages [ ] Are you currently
Breastfeeding? Otherspecify?
10Men only to complete
Bloodinurine [ ] Needtoleanforwardtourinate [ ] Prostateissues [ ] Difficultystartingurination [ ]
Poororweakstream [ ] Incontinence [ ] Upatnightoften [ ] Strongcolour [ ] Strongsmell [ ]
Urgent [ ] Frequent urination [ ] Impotence [ ] Infertility [ ] Lowlibido [ ]
Depression[ ] Sexuallytransmitteddisease [ ] Prostatecheck [ ] (when?) [ ]
Bonedensitycheck[ ] (when?) [ ] Other pleasespecify?

All patients to complete – re your diet

How many glasses or cups of the following do you drink a day:

Water

/

Milk

/

MiloorCocoa

/ Herbaltea

Normaltea

/

Coffee

/

Fizzydrinks/cordial

/ Other
Alcohol – what would you normally drink and how often?
How many teaspoons of sugar do you add daily to drinks or on cereal?
What do you eat of the following? margarine [ ] butter [ ] brownbread [ ] whitebread [ ]
Are you vegetarian or vegan? / Yes [ ]
No [ ] / Do you have sweet cravings? / Yes [ ] No [ ]
Do you use artificial sweeteners? / Yes [ ]
No [ ] / Do you have salt cravings? / Yes [ ] No [ ]
Do you have any other food allergies or intolerances?
Is there any foods you restrict in your diet ie wheat, gluten, dairy etc?
Do you have any suspicions of any foods that upset your digestion, stomach, bowel or give you symptoms ie itchy skin, headaches, constipation? Please list
Do you have a high carbohydrate diet? ie. bread, biscuits, potatoes. Yes [ ] No [ ]
Do you have a good appetite? / Yes [ ] No [ ] / Do you always have breakfast? / Yes [ ] No [ ]
Do you consider your diet to be: Poor [ ] OK [ ] VeryGood [ ]
Please list what you would usually have for breakfast, lunch and dinner. Provide as much detail as possible ie ham,
2 minute noodles, butter, mayonnaise, full milk, soy milk:
Breakfast
Snacks
Lunch
Dinner
Do you smoke? Yes [ ] No [ ] / How many a day? [ ]
Do you use social drugs? Yes [ ] No [ ] / Do you do less than 2 hours exercise a week? [ ]
What sort of exercise do you do and how often?
Do any of your siblings have food allergies or intolerances? Yes [ ] No [ ]
If you have already decided you would like to go ahead with any of the following services please indicate:
Food allergy / intolerance test via a hair sample [ ] $180
Custom suited detox program for 2 - 6 weeks [ ] $300-$450
23 – 40 day weight loss program [ ] $220-$300
Have you completed an active elements mineral assessment on our website?[ ]

If you would like contact information on our recommended services

Yoga [ ] / Physiotherapist [ ] / Osteopath [ ]
Gym [ ] / Massagetherapist [ ] / Colonicirrigation [ ]
Chiropractor [ ] / Pilates [ ] / Personaltrainer [ ]

Thank you for completing this health profile.

Important – Save your document before sending to

Notes:
If possible please bring any blood test results you have had done in the last 3 months - even if you have been told they are OK. Ask the Drs receptionist to email or fax a copy to us or you.
Payments can be made by Eftpos, cheque or cash. No credit facility.
We are located at Anzac House 181 Willis Street (ground floor on the right of front stairs)
Opposite St John’s Church, 100m from Wilson Car park building or street parking in Dixon & Willis Street ($4 per hour).

Client name | page 1