Forms Intake form Are you over 18 years of age?YesNoName* First Last Date of birth* Date Format: DD slash MM slash YYYY Parent's name* First Last GenderMaleFemaleEmail* Best contact number* Phone number Best time to call Address Street Address Suburb State Postcode OccupationReferred by*FriendFamilyDoctorGoogleBingOtherCurrent doctorOther practitionersName of the person who referred youEmergency contact person Name Contact number What specific condition do you want to address in the consultation?*Are there any current medical conditions that you are being treated for?*YesNoWhat is the medical condition or conditions?*Are you currently taking any prescribed medications?*YesNoWhat are the prescribed medications?*Do you take supplements?*YesNoDo you take these supplements regularly?*YesNoWhat are the supplements?*Allergies?*YesNoWhat are you allergic to?*What do you normally eat?List the types of food you normally eat for Breakfast, Lunch, Dinner and snacksWater intake per dayunder 1 litre per day1-2 litres per day2-3 litres per day3+ litres per dayI do not drink waterCoffee intake per dayunder 1 cup per day (1 cup per week)1-2 cups per day2-3 cups per day3 or more cups per dayI do not drink coffeeTea intake per dayunder 1 cup per day (1 cup per week)1-2 cups per day2-3 cups per day3 or more cups per dayI do not drink TeaDo you drink alcohol?YesNoHow much alcohol do you drink?under 1 glass per week1-2 glasses per week3-4 glasses per week5-6 glasses per week7 or more glasses per weekDo you smoke?YesNoHow many smokes do you have per day?1-55-1010-2020+Do you feel you need to lose weight?YesNoDo you have? Diabetes Liver disease, like hepatitis Kidney disease A family history of any of the above? No Do you have any flu like symtoms?YesNoIn the last 14 days, have you been in close contact with someone who has been diagnosed with COVID-19?YesNoDo you had any recent pathology tests?YesNoIf YES please email or bring a copy of these lab results with you to the consultation.Medical Disclaimer I have read and agree to the “Medical Disclaimer” (see below)Appointment Policy I have read and agree to the “Appointment Policy” (see below)Terms of Use & Privacy Policy I have read and agree to the “Terms of Use” and the "Privacy Policy" (see below)
