Initial Consultation Questionnaire

date______

surname______given name(s)______

address______suburb______postcode______

home phone______work phone______

mobile______email ______

date of birth______number of children______

blood group______occupation______

Where did you hear about cbd natural health?

Google / Yahoo / facebook / friend
Yellow Pages Online / NT Pages / True Local / other

Family history: Please mark “S” for self and “F” for family member if you have now or have had in the past any of the following:

acne / cancer / high blood pressure / migraines/headaches
allergies / diabetes / osteoporosis / thyroid problems
arthritis / infertility / eczema/psoriasis / weight problems
asthma / kidney stones / nervous disorders / other

List any medications you are currently taking.

______

______

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

______

______

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

1.______

2.______

3.______

General health questionnaire

0= Never1=Sometimes 2=Regularly (more than twice weekly) 3=Daily basis

Digestion and Dysbiosis

Bloating after meals0123

Abdominal cramps and pain0123

Burp/gas after meals0123

Eat quickly or don’t chew thoroughly0123

Have a burning feeling in stomach indigestion, or take antacids0123

Have less than one bowel movement daily0123

Suffer diarrhoea 0123

Haemorrhoids or rectal pain and bleeding after bowel motion0123

Feel nauseous in the mornings0123

Have bad breath0123

Suffer thrush or urinary tract infections0123

Antibiotics more than twice per yearNoYes

Long term antibiotic use (longer than 1 mth)NoYes

On birth control pill for more than 2 yearsNoYes

Chronic fungal infections of skin or nailsNoYes

Lifestyle – please be reminded your answers are always strictly confidential

Do you smoke? NeverYes Only in the past

Do you take recreational drugs?NeverYesOnly in the past

Immune System

More than 3 colds per yearNoYes

Difficulty shifting an infectionNoYes

Often have a sore throat or swollen glandsNoYes

Suffer asthma, eczema or arthritis NoYes

Liver and Detoxification

Fatty foods cause indigestion0123

Suffer from nausea or vomiting0123

General feeling of poor health0123

Suffer headaches/migraine 0123

Dark circles under eyes0123

Sinus problems or stuffy nose0123

Excessive mucus0123

Chronic cough0123

Strong body odour0123

Muscle or joint aches and pains0123

Asthma or bronchitis0123

Dry or flaky skin and/or hair0123

Feel agitated, restless, angry0123

Skin rashes, itching0123

Yellowing of the skin or eyes0123

Broken sleep/insomnia0123

Energy and Vitality

Feel tired or overworked0123

Find it hard to wake up or get motivated in the morning0123

Need coffee, tea, sugar or tobacco to give you energy0123

Have noticeable energy slumps during the day0123

Get dizzy, shake or become irritable

if you go without food for more than 4 hours0123

Suffer mental confusion or have difficulty concentrating0123

Crave pasta, bread, sugar0123

Stress

Feel stressed, nervous or anxious0123

Feel Irritable, oversensitive0123

Feel overwhelmed with your workload0123

Have you in the past 2 years experienced:

DivorceNoYes

SeparationNoYes

Death in familyNoYes

Financial devastationNoYes

Moving houseNoYes

Starting or losing workNoYes

Mood and Memory

Difficulty concentrating0123

Poor memory 0123

Suffer depression0123

Become easily anxious or is a ‘worry wart’0123

Feel exhausted 0123

Feel overwhelmed and out of control of your life0123

Suffer insomnia0123

Mood swings 0123

Hormonal Health
Women

Are you taking the oral contraceptive pillNoYes

What is your average cycle length ______(longest cycle ______days shortest cycle ______days)

(Period – period -Counting from the first day your period starts till the day before your next period begins))

Do you suffer:

Heavy bleedingNoYes

Painful periodsNoYes

Irregular periodsNoYes

Fertility problems, difficulty conceiving or maintaining a pregnancyNoYes

Reduced libidoNoYes

Mood swings (Irritable, irrational, depression/anxiety)NoYes

Breast tendernessNoYes

STD’s (past or present) NoYes

Any known problems affecting your reproductive organsNoYes

______

Men

Have you had a vasectomyNoYes

Do you suffer from:

Low sperm countNoYes

Undecended testes as a childNoYes

Reduced libidoNoYes

ImpotenceNoYes

STD’s (past or present) NoYes

Weight Management

Where 0 is very satisfied and 3 is very concerned about

How your body:

Looks0123

Feels0123

Body fat0123

Muscle tone0123

Strength0123

Endurance0123

Flexibility0123

Present weight0123

Attractiveness0123

Total

Exercise

Do you exercise? No Yes

Date / kg / %fat / %H20 / visceral / Muscle / Physique rt / Bone mass / Met. age

Practitioner use:

Our Cancellation Policy
In order to serve others, we ask that you offer a courtesy call if you cannot keep your allotted appointment time. A 24hour notice is required for cancellation of appointments without acquiring a "no-show" charge of the full fee of your consultation. Please be considerate.

Scheduled appointments are set up in order to accomplish getting you well. If you cancel your appointment, it may delay your recovery. If you must miss it, it is best to reschedule as soon as possible.

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