Intake Questionnaire – Margherita Step 1 of 7 14% Today’s dateDate of birthSexAgeLast name*First name*Street address*TelephoneHomeWorkMobileEmail* Emergency ContactReferred byPrivate Health ProviderGeneral Practitioner name/suburbYour occupation - CurrentPreviousMarital StatusNo of childrenAre you happy to receive our newsletter (health tips, research & recipes)? Yes No Health AssessmentDo you have any medically diagnosed conditions or injuries?Please state the symptoms which you would most like resolved as your highest priority:What if any prescription medications/supplements are you taking? Please provide dose, quantity & approximate start date:Please select one or more from the following in regard to your sleep pattern: Insomnia Waking once asleep Great Hypersomnia (sleeping a lot) Can’t remember dreams Vivid dreams Teeth-grinding Involuntary daytime napping Unrefreshed on waking (even with adequate sleep) Restless legs Sleep talking Mouth-breathing Snoring Delayed sleep phase (cant fall asleep before midnight) Please circle one or more from the following in regard to your mood/emotions: Depression Anxiety Hyperactive Lack of motivation Continual worrying Addictive tendencies Poor concentration Manic Fidgeting Tendency to “blow up” Restless Obsessive compulsive Perfectionist Impulsive Panic Nervousness Moody (highs & lows) Agitated List your top current stresses and rate then out of 10 (10 being the most stressful)(eg work, relationships, time poor, financial stress, health etc) Please select on the chart the number which reflects your level of energy (1 being great and 10 being fatigued) 1 2 3 4 5 6 7 8 9 10 LifestyleDo you use recreational drugs? Yes No Now Past How often would you use pharmaceutical/over the counter drugs?Do you smoke? Yes No If yes how many? Now Past Do you exercise? Yes No How often?What do you do for relaxation & how often? Food InformationDo you have any known allergies?Please select any of the following which you are intolerant to or which bother you Dried fruit Onions Garlic Eggs Wine Chocolate Cheese Tomatoes Capsicum Dairy Fish Bread/pasta Gluten Nuts Citrus Additives Perfumes/chemicals OtherDo you crave any of the following Cakes Sugar Biscuits Pastries Chocolate Salt OtherPlease provide your fluid intake per day:Watertap/bottled/filtered/rainwaterCoffeeinstant/decaffeinated/fresh beanFruit juiceSoft drinks/diet drinksSports drinksBlack teaSugar added to drinks/foodAlcohol (now)Alcohol (past)wine/spirits/beerHerbal teasPlease provide an outline of what you eat For more detail please use the cronometer app: https://cronometer.com/BreakfastFood and Drink (Please include brand names)Amount (weight or measurement)How was it prepared? (steamed, fried with oil, roasted)How did you feel afterwards? (content, still hungry, sluggish etc)SNACKFood and Drink (Please include brand names)Amount (weight or measurement)How was it prepared? (steamed, fried with oil, roasted)How did you feel afterwards? (content, still hungry, sluggish etc)LUNCHFood and Drink (Please include brand names)Amount (weight or measurement)How was it prepared? (steamed, fried with oil, roasted)How did you feel afterwards? (content, still hungry, sluggish etc)SNACKFood and Drink (Please include brand names)Amount (weight or measurement)How was it prepared? (steamed, fried with oil, roasted)How did you feel afterwards? (content, still hungry, sluggish etc)DINNERFood and Drink (Please include brand names)Amount (weight or measurement)How was it prepared? (steamed, fried with oil, roasted)How did you feel afterwards? (content, still hungry, sluggish etc)SNACKFood and Drink (Please include brand names)Amount (weight or measurement)How was it prepared? (steamed, fried with oil, roasted)How did you feel afterwards? (content, still hungry, sluggish etc)Do you have any philosophies around what you eat? (eg vegetarian, vegan etc): MaleDo you suffer from an inability to maintain an erection? Yes No Do you have heaviness/hardness/pain in any of the reproductive areas? Yes No Are you losing body hair? Yes No In regard to your flow of urine have you noticed a diminished strength of stream? Yes No In regard to your flow of urine do you have difficulty stopping and starting? Yes No FemalePlease describe your menstrual flow: absent perimenopausal menopausal menstrual How many days does your flow last?Is the flow normal heavy light How often does your flow come? Every 15-20 days 28-29 days 30-35 days Irregular Do you suffer premenstrual tension? Yes No Do you suffer pain? Yes No If so which symptoms? Painful breasts Exaggerated responses Other OtherHow many times have you been pregnant?Are you taking anything which effects your hormones? Pill Implanon Mirena HRT Other OtherIf so is this to control any of the following: Painful periods Irregular periods Acne Heavy periods Other Please tick &/ or comment on any symptoms which you suffer or have suffered from regularly:Bloating (related to digestion)SUFFER NOWSUFFERED IN THE PASTHeartburnSUFFER NOWSUFFERED IN THE PASTRefluxSUFFER NOWSUFFERED IN THE PASTExcessive burpingSUFFER NOWSUFFERED IN THE PASTStomach painSUFFER NOWSUFFERED IN THE PASTStool – constipation (miss days or straining)SUFFER NOWSUFFERED IN THE PASTStool – diarrhea/loose stoolsSUFFER NOWSUFFERED IN THE PASTStool – appearance other than dark brownSUFFER NOWSUFFERED IN THE PASTFlatulence - excessiveSUFFER NOWSUFFERED IN THE PASTThrushSUFFER NOWSUFFERED IN THE PASTHemorrhoids/varicose veins/spider veinsSUFFER NOWSUFFERED IN THE PASTNauseaSUFFER NOWSUFFERED IN THE PASTWaking at night to urinate (if yes how often?)SUFFER NOWSUFFERED IN THE PASTBladder problems – urinary tract infectionSUFFER NOWSUFFERED IN THE PASTcolds/flus/sore throat/coughs more than twice per yearSUFFER NOWSUFFERED IN THE PASTHayfever / sinus problemsSUFFER NOWSUFFERED IN THE PASTRespiratory problemsSUFFER NOWSUFFERED IN THE PASTasthmaSUFFER NOWSUFFERED IN THE PASTSkin problems–acne/eczema/psoriasis/itchy/dry/tineaSUFFER NOWSUFFERED IN THE PASTMuscle cramps or achesSUFFER NOWSUFFERED IN THE PASTBack painSUFFER NOWSUFFERED IN THE PASTMigrainesSUFFER NOWSUFFERED IN THE PASTHeadachesSUFFER NOWSUFFERED IN THE PASTDizzinessSUFFER NOWSUFFERED IN THE PASTHigh blood pressureSUFFER NOWSUFFERED IN THE PASTLow blood pressureSUFFER NOWSUFFERED IN THE PASTHeart problemsSUFFER NOWSUFFERED IN THE PASTHigh cholesterolSUFFER NOWSUFFERED IN THE PASTCold hands and feetSUFFER NOWSUFFERED IN THE PASTFeel fluidy/swollen – eg hot weather/plane ride etcSUFFER NOWSUFFERED IN THE PASTLow libidoSUFFER NOWSUFFERED IN THE PASTinfertilitySUFFER NOWSUFFERED IN THE PASTanemiaSUFFER NOWSUFFERED IN THE PASTForgetful/vagueSUFFER NOWSUFFERED IN THE PASTHair lossSUFFER NOWSUFFERED IN THE PASTViruses – eg herpes/chicken pox etcSUFFER NOWSUFFERED IN THE PASTPlease select any conditions which family members (parents, siblings, grandparents, children) have or had: heart disease high blood pressure skin problems respiratory problems obesity cancer diabetes mood disorders renal problems depression celiac disease Allergies blood disorders osteoporosis thyroid disorders bowel disorders hormonal problems OtherPlease give a brief description of the history of your health including any diagnosis/conditions/injuries starting from most current going back to childhood: Current Year Condition/Event/Injury/trauma/diagnosisConsent* I hereby agree and understand that the treatment/advice given will include one or more of the following; dietary prescription, lifestyle prescription, nutritional/herbal supplements and screening tests, which I knowingly and willingly consent to undergo of my own free will. At any time I may reject any treatment or advice without prejudice from the practitioner. I understand that nutritional/herbal supplements are prescribed in a therapeutic fashion and if circumstances change (e.g. pregnancy, cessation/commencement of pharmaceutical drugs etc) from what was presented to the practitioner, I will notify the practitioner immediately, so treatment/advice can alter accordingly if required.Signature*Date* MM slash DD slash YYYY Thanks for filling out the main questionaire, finally we just need to get an idea of how you have been feeling in the last week Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 - Did not apply to me at all - NEVER 1 - Applied to me to some degree, or some of the time - SOMETIMES 2 - Applied to me to a considerable degree, or a good part of time - OFTEN 3 - Applied to me very much, or most of the time - ALMOST ALWAYSI found it hard to wind down 0 1 2 3 I was aware of dryness of my mouth 0 1 2 3 I couldn’t seem to experience any positive feeling at all 0 1 2 3 I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion) 0 1 2 3 I found it difficult to work up the initiative to do things 0 1 2 3 I tended to over-react to situations 0 1 2 3 I experienced trembling (eg, in the hands) 0 1 2 3 I felt that I was using a lot of nervous energy 0 1 2 3 I was worried about situations in which I might panic and make a fool of myself 0 1 2 3 I felt that I had nothing to look forward to 0 1 2 3 I found myself getting agitated 0 1 2 3 I found it difficult to relax 0 1 2 3 I felt down-hearted and blue 0 1 2 3 I was intolerant of anything that kept me from getting on with what I was doing 0 1 2 3 I felt I was close to panic 0 1 2 3 I was unable to become enthusiastic about anything 0 1 2 3 I felt I wasn’t worth much as a person 0 1 2 3 I felt that I was rather touchy 0 1 2 3 I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat) 0 1 2 3 I felt scared without any good reason 0 1 2 3 I felt that life was meaningless 0 1 2 3 Thank you for completing this form, look forward to moving you to better health 🙂
