Basic Details

Primary health problems/symptoms:

Name of health issue Mild/moderate/severe Year of onset



Was the onset of your symptoms fairly sudden or gradual?
What do you believe or suspect triggered your symptoms?

Present medications/supplements/herbs:

Include contraceptives & medications taken regularly (e.g. antacids or aspirin).
Name of product Dose (e.g. 30 mg) Duration taken (e.g. 6 months) Reason(s) (e.g. for acne) Does it help? (no, slightly, moderately or completely)  

Are you undergoing any other treatments or therapies? e.g. counselling, meditation, acupuncture, etc.

Name of treatment/therapy Duration Does it help? (no, slightly, moderately, markedly)  

Previous Medical History

(Please check and fill detail for all that apply)

DRUG HISTORY

Name of Drug/s Dosage & Frequency Duration Taken Reason for prescribed/self-administered drugs
Any past/current use of: Laxatives, Antacids, Painkillers, Sleeping Pills, Oral Contraception, Antibiotics, Vitamins/Minerals Supplements, Other?
Name of Product Type Duration Taken Past/Current Use

ALLERGIES

Known allergies to drugs, foods, environment etc - past and present

FAMILY HISTORY

Major health problems in the family

LIFESTYLE

Describe your Home Situation, Work Situation, Hobbies/Pastimes, Recreational drugs usage

EXERCISE HABITS

Describe duration, intensity, frequency

REVIEW OF BODY SYSTEMS

NERVOUS SYSTEM

(Please check and choose all that apply)

DIGESTIVE SYSTEM

(Please check and choose all that apply)

IMMUNITY

(Please check and choose all that apply)

RESPIRATORY SYSTEM

(Please check and choose all that apply)

URINARY SYSTEM

(Please check and choose all that apply)

CARDIOVASCULAR SYSTEM

(Please check all that apply)

MUSCULOSKELETAL

(Please check all that apply)

SKIN

(Please check and choose all that apply)

REPRODUCTIVE (MALE/FEMALE)

(Please check and choose all that apply)

ENDOCRINE

(Please check and choose all that apply)

DIET

(time, what was consumed, any reactions observed i.e. bloating, mood changes etc)
Sugar
Dairy Products
Caffeine Drinks
White bread/pasta/ rice/noodles
Chicken
Fresh fruits
Table salt
Fish/seafood
Vegetables
Fried foods
Red meat
Green salads

CARBOHYDRATE METABOLISM

(Please check all that apply)

OTHER RELEVANT INFORMATION