Pre-consultation Health Questionnaire

Pre-consultation Health Questionnaire
Title (Mr, Mrs, Ms, Miss)
Name

First Name Last Name
E-mail
Address

Street Address

Street Address Line 2

City County

Postal Code Country
Phone Number

Area Code Phone Number
Date of birth
Age
Height CM
Weight
Hip / waist measurement (cm)
Profession
Marital Status
Health Concerns:

Please choose one or two symptoms (physical or mental) which bother you the most.

These will be your main health concerns, which I will support and could be symptoms such as stress, frequent colds, asthma, high blood pressure, shortness of breath, tiredness, thyroid issues, diabetes etc.
Symptom 1
How long have you had symptom 1?
Symptom 2
How long have you had symptom 2?
Are there any activities which the symptoms prevent you from doing
If you have consulted a therapist, consultant or practitioner for the above symptoms, please provide details below
Which type of consultant, specialist or therapist
Date
Diagnosis, treatment and medications received
Previous medical history

For example: Allergies, anxiety or depression, arthritis or rheumatism, asthma or breathing problems, bowel problems, cancer, diabetes, drug or alcohol dependence, ear, eye or throat problems, eczema or skin conditions, epilepsy, heart conditions, hypertentionsin, onfections or diseases (e.g. mumps, measles, chicken pox), kidney conditions, menstrual/mrnopausal conditions, osteoporosis, sleep problems, stomach ulcers, thyroid problems, tumours, urinary tract conditions.
Childhood illnesses (please include age)
Recurrent illnesses, operations or previous diagnosis (please include age)
Blood pressure
Cholesterol (if known)
Medications
Prescription medications (please include dosage and frequency)
Non-prescription medications e.g. paracetamol, laxatives, anti-histamines etc
Supplements and herbal remedies
Please list any recently discontinued medications or supplements?
Family medical history

Please provide details below of family health conditions: e.g. angina, allergies, alzheimer's, arthritis, asthma, blood pressure, cancer, dementia, diabetes, heart disease, lung disease, osteoporosis, parkinson's disease, skin conditions, stroke:
Parents & grandparents
Siblings
Please tick those boxes that relate to your present diet

Mixed food diet (animal & vegetable sources) Pescetarian Flexitarian Vegetarian (lacto) Lacto ovo Vegan Raw food diet Macrobiotic diet Fat restriction Salt restriciton Starch/carbohydrate restriction Paleo FODMAP Blood type diet Low GL
Other diet
Additional information
Please add any additional information or health goals and concerns here
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm