Step 1

Basic Details

Primary health problems/symptoms:

Name of health issue Mild/moderate/severe Year of onset
Step 2

Present medications/supplements/herbs:

Include contraceptives & medications taken regularly (e.g. antacids or aspirin).
Name of product Dose (e.g. 30 mg) Duration taken (e.g. 6 months) Reason(s) (e.g. for acne) Does it help? (no, slightly, moderately or completely)

Are you undergoing any other treatments or therapies? e.g. counselling, meditation, acupuncture, etc.

Name of treatment/therapy Duration Does it help? (no, slightly, moderately, markedly)

Previous Medical History

(Please check and fill detail for all that apply).
Childhood Diseases
Accidents
Operation/Surgery
Medical results i.e. blood tests
Major recurrent Illnesses(i.e. Hepatitis, Jaundice, Diabetes)
General Health
Hospitalisations
Immunisations
Dental Metal Fillings: How Many?
Hormonal/ Steroid treatments

DRUG HISTORY

Name of Drug/s Dosage & Frequency Duration Taken Reason for prescribed/self-administered drugs
Step 3

Any past/current use of: Laxatives, Antacids, Painkillers, Sleeping Pills, Oral Contraception, Antibiotics, Vitamins/Minerals Supplements, Other?

Name of Product Type Duration Taken Past/Current Use

ALLERGIES

Chemical Sensitivities

FAMILY HISTORY

LIFESTYLE

EXERCISE HABITS

Step 4

REVIEW OF BODY SYSTEMS

NERVOUS SYSTEM

(Please check and choose all that apply)
Sleep Disturbance/ Night sweats/Dreams Headache/Migraine Visual Disturbance
Numbness/tingling Depression Anxiety/Stress
Dizziness/ Vertigo/ Weakness Fainting/Fits Mood Changes/ Fluctuating emotions
Poor Memory/Concentration Sleep patterns - difficulty/easy going to sleep, difficulty/easy waking
Sleep
Describe quality
Stress Level from 1 to 10

Energy Level from 1 to 10 :

Morning
Mid-day
Afternoon
Evening

DIGESTIVE SYSTEM

(Please check and choose all that apply)
Poor/Large Appetite Nausea/Vomiting Weight Change- Increase/Decrease
Flatulence/Bloating/Abdominal Pain Indigestion/Reflux/Acidity Dental Problems
Difficulty swallowing Rectal bleeding/Haemorrhoids Unusual Stool Colour/ Inconsistency/ Irregularity/ Diarrhoea/ Constipation/ Pain/Blood
Bowel movements
/day

IMMUNITY

(Please check and choose all that apply)
Recurrent Infections Night sweats Recurrent/Chronic conditions
Slow wound-healing time Frequency/Length of colds/flus

RESPIRATORY SYSTEM

(Please check and choose all that apply)
Earache/Tinnitus/Hearing Loss Sputum/Post nasal drip Cough
Recurrent Infections Catarrh/Sinus Sore Throat
Wheeze/Difficulties-inhaling or exhaling/Tightness of chest

URINARY SYSTEM

(Please check and choose all that apply)
Frequency/Urgency Pain/Burning/Dysuria Haematuria - blood in urine
Loin Pain Difficulty Starting Weak Stream/Dribbling/Incontinence
Urine Character-Colour/Quality/Smell
Step 5

CARDIOVASCULAR SYSTEM

(Please check and choose all that apply)
Chest Pain Shortness of breath Palpitations
Oedema/swelling Varicose Veins Cold Extremities
Blood Pressure

MUSCULOSKELETAL

(Please check and choose all that apply)
Joint Pain/Stiffness Joint Swelling Back/Neck Pain
Injuries Spasms /cramps

SKIN

(Please check and choose all that apply)
Acne/Dry/Oily Rashes Herpes
Eczema/Psoriasis Fungal Infections

REPRODUCTIVE (MALE/FEMALE)

(Please check and choose all that apply)
Menarche Cycle Length - Regularity/Duration Menopause- Peri/Post Loss of libido
STDs Infertility/Impotence/Dysfunction Pregnancies/Miscarriages/Terminations
Benign prostate enlargement (BPH) Cycle Length - Regularity/Duration
Dysmenorrhoea/Clotting/Colour/Amount, P.M.S (type)

ENDOCRINE

(Please check and choose all that apply)
Poor temperature regulation (aversion to cold etc.) Poor energy levels throughout the day (fatigue) Weight gain/loss
Goitre Loss/growth of body hair

DIET

(time, what was consumed, any reactions observed i.e. bloating, mood changes etc)
Do you follow any specific dietary guidelines (i.e. vegetarian, kosher, etc)?
Step 6

How often do you consume the following: (0: never, 1: 1-2 x a month, 2: weekly, 3: 3x week, 4:daily) Please choose

Sugar
Dairy Products
Caffeine Drinks
White bread/pasta/ rice/noodles
Chicken
Fresh fruits
Table salt
Fish/seafood
Vegetables
Fried foods
Red meat
Green salads

CARBOHYDRATE METABOLISM

(Please check all that apply)
Sugar/Chocolate Cravings Shakiness between meals Irritability
Grazer Emotional Eater Sleepiness after eating
What is 3 + 0 ? =