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FIRST CONSULTATION
Type answers to applicable questions, then
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bottom of page). Please complete form well before your appointment.
THANK YOU.
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Name
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First
Last
Address
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Phone Numbers
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Email
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Date of Birth
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Occupation
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Doctor’s or Health Professional’s Name
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Name of Private Health Insurance
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How Did You Hear About This Clinic?
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HEALTH HISTORY
Major Illnesses or Operations
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Blood Group, Height & Weight
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FAMILY HEALTH HISTORY
Family Health Problems
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CURRENT HEALTH
Allergies
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Health Issues, Symptoms, Reason For Consultation
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Recent Medical Investigations
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Prescribed Medicines
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Supplements/Natural Medicines
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GENERAL HEALTH & LIFESTYLE
Appetite, Usual Diet & Daily Water Intake
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Tea, Coffee & Alcohol Intake Per Day/Week
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Type & Frequency Of Exercise?
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SPECIFICS FOR SKIN CONDITIONS
Medical Diagnosis of Skin Condition
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Onset & Duration of Skin Condition
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What Aggravates or Helps Your Skin?
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Is This Condition Always Present? Explain
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Past Medicines & Topical Treatments
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Current Medicines & Topical Treatments
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SPECIFICS FOR BABYS / INFANTS
Parents Names
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Pregnancy & Birth History
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Babys Medical Conditions, Operations, Injuries
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Baby’s Problems & Behaviour
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Sleep Pattern
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If Breast Fed – Usual Pattern, Problems, Mothers Diet
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Other Fluids & Age Introduced
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Usual Diet & Water Intake
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