New Client Questionnaire


Please allow 20 minutes to complete this form prior to your appointment. This background information will provide us with an important insight into your health history and allow us more time to discuss further details during your consultation. If there is a question you are unsure about please answer to the best of your ability or leave blank. Some questions may be duplicated in order to easily assess different body systems.

 

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1
Personal details
First name
Last name
Date of birth
Gender
Contact details
Address
Mobile phone
Home phone
Private heath fund
Health fund name
Membership number
Reference number
Emergency contact details
Contact name
Phone number
How did you find out about Alchemy Health & Wellbeing?
Who were you referred by?
Other (please provide details)
Please select main area/s of concern
Other (please provide details)
Height (cm)
Weight (kg)

Your Body Mass Index (BMI) = [field34 / ((field33 / 100) * (field33 / 100))]

Please indicate if any of your relatives have sufferedfrom the following conditions:
Allergies
Ankylosing spondylitis
Anxiety
Asthma
Biploar/Schizophrenia
Cancer
Coeliac disease
Crohn’s disease
Dementia
Depression
Diabetes
Eczema
Gout
Haemochromatosis
Heart disease
High blood pressure
Lupus
Mental disorder
Osteoporosis
Renal disease
Rheumatoid arthritis
Stroke
Thyroid disease
Ulcerative colitis
Other
Other (details)
Have you had any surgeries
Please provide details
INFANCY - birth to 12 months
Did your mother have excessive nausea while pregnant with you?
Were there any complications during your birth?
Did your mother have postnatal depression?
Were you breastfed?
Were you bottle fed?
Did you suffer eczema?
Did you suffer reflux, colic or any other feeding issues?
Did your mother have excessive nausea while pregnant with you?
Were you vaccinated?
CHILDHOOD HEALTH - 1 year to puberty
Did you suffer from tonsilitis?
Ear infections?
Frequent colds or flu?
Frequent antibiotic use?
ADOLESCENT HEALTH
Did you suffer from acne?
Stretch marks?
Depression?
Eating disorder of any kind?
Glandular fever or chronic fatigue?
24 HOUR DIET & ACTIVITY LOG
Please list all food and beverages you have eaten in the past 24 hours.
Water (# of cups per day)
Breakfast
Food/BeverageTime
×
×
(2)
Lunch
Food/BeverageTime
×
×
(2)
Dinner
Food/BeverageTime
×
×
(2)
Snacks
Food/BeverageTime
×
×
(2)
Condiments
Food/BeverageTime
×
×
(2)
Other
Food/BeverageTime
×
×
(2)
Exercise
TypeDuration
×
×
(2)
DIGESTION
Do you suffer belching, burping or bloating?
Fullness or indigestion after meals?
Undigested food in your stool?
Constipation?
Diarrhoea?
Nausea or vomiting?
Abdominal pain?
Blood or mucus in your stool?
Have you ever had traveller’s diarrhoea?
Flatulence?
Antibiotic use?
Oral contraceptive pill use?

Digestion calculation

[FIELD223 + FEILD356 + FEILD355 + FEILD354 + FEILD353 + FEILD352 + FEILD351 + FEILD540 + FEILD350 + FEILD349 + FEILD348 + FEILD347]

ALLERGIES
Do you suffer from reactions to any foods including additives such as MSG?
Recurrent nasal congestion?
Eczema/dermatitis or asthma?
Itchy ears?
Recurrent throat irritation or coughing?
Hay fever?

Allergies calculation

Are you allergic to any medications, herbs or supplements?
Please specify
Are you allergic or reactive to any chemicals or foods?
Please specify
Do you suffer from burning feet?
Trouble sleeping?
Excessive eye watering?
Are your eyes sensitive to light?
Mouth soreness?
Reduced appetite?
Do you feel nervous or edgy?
Do you have a tremor in your hands?
Cracks in the corners of your mouth?
How often do you dream?
Vivid dream recall?
Eye irritation?
Pins & needles?
Increased clumsiness?
Increased forgetfulness?

B Vitamins Calculation

[FIELD234 + FIELD268 + FIELD269 + FIELD270 + FIELD271 + FIELD272 + FIELD273 + FIELD274 + FIELD275 + FIELD276 + FIELD277 + FIELD278 + FIELD279 + FIELD280 + FIELD281]

Do you suffer from muscle pain/weakness?
Have you noticed loosening of your teeth?

Calcium Calculation

[FIELD240 + FIELD383]

Do you get white spots on your nails?
Recurrent infections, coughs or colds?
Slow wound healing?
Increased hair loss and decreased quality?
Bad breath?
Reduced taste or smell sensation?

Zinc Calculation

[FIELD239 + FIELD386 + FIELD387 + FIELD388 + FIELD389 + FIELD390]

Do you suffer from muscle cramps?
Dizziness?
Muscle twitching?
Tremors?
Palpitations?

Magnesium Calculation

[FIELD238 + FIELD392 + FIELD393 + FIELD394 + FIELD395]

How often do you suffer pain?
Does pain effect your activities?
Does pain effect your sleep?

Pain Calculation

[FIELD237 + FIELD398 + FIELD397]

Do you often feel irritable?
Lack of motivation?
Do you skip meals?
Are you vegetarian?

Protein Calculation

[FIELD236 + FIELD401 + FIELD402 + FIELD403]

Slow wound healing?
Bleeding gums?
Bumpy skin on arms, legs or buttocks?
Do you bruise easily?
Aching legs?
Recurrent infections?

Vitamin C Calculation

[FIELD235 + FIELD405 + FIELD406 + FIELD407 + FIELD408 + FIELD409]

Dry itchy eyes?
Deterioration of night vision?
Dry mouth?

Vitamin A Calculation

[FIELD411 + FIELD412 + FIELD413]

Increased clumsiness?
Poor coordination?
Vision deterioration?

Vitamin E Calculation

[FIELD415 + FIELD416 + FIELD417]

Do you wake up tired in the morning?
Do you feel tired during the day?
Poor recovery from exertion?

Energy Calculation

[FIELD254 + FIELD419 + FIELD420]

Do you suffer excessive ear wax?
Dry brittle hair?
Dandruff?
Brittle nails?
Dry skin?
Dry cracked heels?

ESSENTIAL FATTY ACIDS Calculation

[FIELD255 + FIELD422 + FIELD423 + FIELD424 + FIELD425 + FIELD426]

Poor concentration?
Short-term memory loss?
Do you feel depressed or down?
Does your mind feel foggy?

Brian Function Calculation

[FIELD256 + FIELD428 + FIELD429 + FIELD430]

Do you react to chemicals?
Do you drink alcohol?
Do you experience unexplained itching that is worse at night?
Thinning of armpit or pubic hair?

Brian Function Calculation

[FIELD256 + FIELD428 + FIELD429 + FIELD430]

Do you feel the cold more than others?
Cold hands and feet?
Hair loss?
Poor mental clarity?
Poor memory?
Do you have a low sex drive?

Thyroid Calculation

[FIELD258 + FIELD439 + FIELD440 + FIELD442 + FIELD443]

Do you get tired after meals?
Easily gain weight?
Do you feel shakey or jittery when you go without food?
Sweet cravings?
Hunger related anxiety?

Insulin Calculation

[FIELD260 + FIELD445 + FIELD446 + FIELD447 + FIELD448]

Do you suffer poor exercise tolerance?
Dark circles under the eyes?
Light headed upon standing up?
Tiredness 1-2 hrs after eating?
Do your socks leave marks on your ankles?
How often do you feel stressed?

CORTISOL/ADRENALIN Calculation

[FIELD259 + FIELD450 + FIELD451 + FIELD452 + FIELD453 + FIELD454 + FIELD455]

Have you ever been exposed to chemical fumes?
Have you ever lived near aerial crop spraying?
Do you ever handle pesticides/herbicides or solvents?
Have you ever lived near a major road?
Have you ever been exposed to farming related chemicals such as cattle dip?
Do you use household pesticides or herbicides such as round up?
Have you ever been exposed to asbestos?

CHEMICAL EXPOSURE Calculation

[FIELD456 + FIELD478 + FIELD477 + FIELD476 + FIELD475 + FIELD474 + FIELD473]

Do you have or have you ever had amalgam fillings?
Do you have root canal fillings?
Have you renovated any old houses?
Have you ever been involved in any cattle or sheep dipping?
Have you played with mercury?
Have you ever had regular contact with lead?
Have you had dental extractions?
Recurrent gum infections?
Gum recessions?
Have you ever done furniture restoral or lead lighting?
Do you smoke?
Do you cook with aluminium saucepans or use coffee pods?

HEAVY METALS Calculation

[FIELD472 + FIELD471 + FIELD470 + FIELD469 + FIELD468 + FIELD467 + FIELD466 + FIELD465 + FIELD464 + FIELD463 + FIELD462 + FIELD461]

Please complete the following for your most recent menstrual cycle, only for the week before, the week after and during your period.

Did you experience any of the following in the week BEFORE your last period?

Anxiety
Irritability
Mood swings
Nervous tension
Headaches
Fatigue
Dizziness or fainting
Palpitations
Sweet cravings
Depression
Crying
Forgetfulness
Confusion
Insomnia
Weight gain >1.5kg
Swollen extremities
Breast tenderness
Abdominal bloating

Week BEFORE last period calculation

[FIELD263 + FIELD302 + FIELD301 + FIELD300 + FIELD299 + FIELD298 + FIELD297 + FIELD296 + FIELD488 + FIELD487 + FIELD486 + FIELD485 + FIELD484 + FIELD483 + FIELD482 + FIELD491 + FIELD490 + FIELD489]

Did you experience any of the following in the week AFTER your last period?

Anxiety
Irritability
Mood swings
Nervous tension

Week AFTER last period

[FIELD494 + FIELD497 + FIELD496 + FIELD495]

OTHER SYMPTOMS AROUND MENSTRUATION
Oily skin
Acne
Cramps
Cramps first 2 days of period
Backache first 2 days of period

OTHER SYMPTOMS AROUND MENSTRUATION

[FIELD285 + FIELD502 + FIELD501 + FIELD500 + FIELD499]

Hot flushes?
Vaginal dryness?
Mood swings?
Night sweats?
Reduced sex drive?

OESTROGEN DEFICIENCY Calculation

[FIELD314 + FIELD507 + FIELD506 + FIELD505 + FIELD504]

Do you suffer bloating, weight gain or water retention?
Irritability/anxiety
Breast pain/tenderness
Painful period cramping

OESTROGEN EXCESS/PROGESTERONE DEFICIENCY

[FIELD313 + FIELD511 + FIELD510 + FIELD509]

General
Do you take the oral contraceptive pill or HRT?
Have you ever had an IUD, Mirena, Implanon or Depo Provera?
Have you ever had an abnormal pap smear?
Difficult pregnancies/births?
Have you experienced fertility/conception issues?
When was your last pap smear?
What is your typical cycle length?
When was your last breast check?
How many children do you have?
Do you feel depressed?
Do you feel easily addicted to activities?
Poor concentration?
Negative self image?
Thoughts of angred or hatred?
Are you argumentative?
Are you physically or verbally abused?
How much do you work per week?
How often do you avoid contact with close friends and family?
Do you feel alone?

Emotional History Calculation

[FIELD526 + FIELD531 + FIELD530 + FIELD529 + FIELD528 + FIELD527 + FIELD535 + FIELD543 + FIELD542 + FIELD541]

Medication
MedicationDoseReason
×
×
(2)
Supplement
MedicationDoseReason
×
×
(2)
Have you ever taken:
Heartburn/reflux medication
Oral contraceptive Pill
Antibiotics
Chemotherapy drugs
Hormone replacement therapy
Oral prednisone/cortisone
Cortisone cream
Asthma medication
Immunosuppressants
Statement
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