First Consultation (Form)

FIRST CONSULTATION

Type answers to applicable questions, then HIT SUBMIT (bottom of page). Please complete form well before your appointment. THANK YOU.

* Indicates required field

Name *

First

Last

Address *

Phone Numbers *

Email *

Date of Birth *

Occupation *

Doctor’s or Health Professional’s Name *

Name of Private Health Insurance *

How Did You Hear About This Clinic? *

HEALTH HISTORY

Major Illnesses or Operations *

Blood Group, Height & Weight *

FAMILY HEALTH HISTORY

Family Health Problems *

CURRENT HEALTH

Allergies *

Health Issues, Symptoms, Reason For Consultation *

Recent Medical Investigations *

Prescribed Medicines *

Supplements/Natural Medicines *

GENERAL HEALTH & LIFESTYLE

Appetite, Usual Diet & Daily Water Intake *

Tea, Coffee & Alcohol Intake Per Day/Week *

Type & Frequency Of Exercise? *

SPECIFICS FOR SKIN CONDITIONS

Medical Diagnosis of Skin Condition *

Onset & Duration of Skin Condition *

What Aggravates or Helps Your Skin? *

Is This Condition Always Present? Explain *

Past Medicines & Topical Treatments *

Current Medicines & Topical Treatments *

SPECIFICS FOR BABYS / INFANTS

Parents Names *

Pregnancy & Birth History *

Babys Medical Conditions, Operations, Injuries *

Baby’s Problems & Behaviour *

Sleep Pattern *

If Breast Fed – Usual Pattern, Problems, Mothers Diet *

Other Fluids & Age Introduced *

Usual Diet & Water Intake *

Submit