Step 1
Basic Details
Full Name :
*
Select Gender :
*
Select Gender
Male
Female
Occupation :
Date of Birth :
*
Weight(kg) :
Height(cm) :
Blood Type :
Select Blood type
O+
O-
A+
A-
B+
B-
AB+
AB-
Blood Pressure :
Relationship Status :
Relationship Status
single
married
widowed
Divorced
Number Of Children :
Are you pregnant,planning or lactating :
Email Address :
*
Address :
Phone:
Country :
Singapore
Jersey
Guernsey
Tristan da Cunha
Isle of Man
Kosovo, Republic of
Ascension Island (British)
Canary Islands
St. Martin (French part)
St. Barthelemy
South Sudan
Palestinian Territory, Occupied
Curacao
Bonaire, Sint Eustatius and Saba
Aaland Islands
Serbia
Montenegro
Zimbabwe
Zambia
Democratic Republic of Congo
Yemen
Western Sahara
Wallis and Futuna Islands
Virgin Islands (U.S.)
Virgin Islands (British)
Viet Nam
Venezuela
Vatican City State (Holy See)
Vanuatu
Uzbekistan
Uruguay
United States Minor Outlying Islands
United States
United Kingdom
United Arab Emirates
Ukraine
Uganda
Tuvalu
Turks and Caicos Islands
Turkmenistan
Turkey
Tunisia
Trinidad and Tobago
Tonga
Tokelau
Togo
Thailand
Tanzania, United Republic of
Tajikistan
Taiwan
Syrian Arab Republic
Switzerland
Sweden
Swaziland
Svalbard and Jan Mayen Islands
Suriname
Sudan
St. Pierre and Miquelon
St. Helena
Sri Lanka
Spain
South Georgia & South Sandwich Islands
South Africa
Somalia
Solomon Islands
Slovenia
Slovak Republic
Singapore
Sierra Leone
Seychelles
Senegal
Saudi Arabia
Sao Tome and Principe
San Marino
Samoa
Saint Vincent and the Grenadines
Saint Lucia
Saint Kitts and Nevis
Rwanda
Russian Federation
Romania
Reunion
Qatar
Puerto Rico
Portugal
Poland
Pitcairn
Philippines
Peru
Paraguay
Papua New Guinea
Panama
Palau
Pakistan
Oman
Norway
Northern Mariana Islands
Norfolk Island
Niue
Nigeria
Niger
Nicaragua
New Zealand
New Caledonia
Netherlands Antilles
Netherlands
Nepal
Nauru
Namibia
Myanmar
Mozambique
Morocco
Montserrat
Mongolia
Monaco
Moldova, Republic of
Micronesia, Federated States of
Mexico
Mayotte
Mauritius
Mauritania
Martinique
Marshall Islands
Malta
Mali
Maldives
Malaysia
Malawi
Madagascar
FYROM
Macau
Luxembourg
Lithuania
Liechtenstein
Libyan Arab Jamahiriya
Liberia
Lesotho
Lebanon
Latvia
Lao People's Democratic Republic
Kyrgyzstan
Kuwait
Korea, Republic of
North Korea
Kiribati
Kenya
Kazakhstan
Jordan
Japan
Jamaica
Italy
Israel
Ireland
Iraq
Iran (Islamic Republic of)
Indonesia
India
Iceland
Hungary
Hong Kong
Honduras
Heard and Mc Donald Islands
Haiti
Guyana
Guinea-Bissau
Guinea
Guatemala
Guam
Guadeloupe
Grenada
Greenland
Greece
Gibraltar
Ghana
Germany
Georgia
Gambia
Gabon
French Southern Territories
French Polynesia
French Guiana
France, Metropolitan
Finland
Fiji
Faroe Islands
Falkland Islands (Malvinas)
Ethiopia
Estonia
Eritrea
Equatorial Guinea
El Salvador
Egypt
Ecuador
East Timor
Dominican Republic
Dominica
Djibouti
Denmark
Czech Republic
Cyprus
Cuba
Croatia
Cote D'Ivoire
Costa Rica
Cook Islands
Congo
Comoros
Colombia
Cocos (Keeling) Islands
Christmas Island
China
Chile
Chad
Central African Republic
Cayman Islands
Cape Verde
Canada
Cameroon
Cambodia
Burundi
Burkina Faso
Bulgaria
Brunei Darussalam
British Indian Ocean Territory
Brazil
Bouvet Island
Botswana
Bosnia and Herzegovina
Bolivia
Bhutan
Bermuda
Benin
Belize
Belgium
Belarus
Barbados
Bangladesh
Bahrain
Bahamas
Azerbaijan
Austria
Australia
Aruba
Armenia
Argentina
Antigua and Barbuda
Antarctica
Anguilla
Angola
Andorra
American Samoa
Algeria
Albania
Afghanistan
Postal Code :
What are your immediate and long-term health goals ?
Primary health problems/symptoms:
Name of health issue
Mild/moderate/severe
Year of onset
+
Was the onset of your symptoms fairly sudden or gradual?
What do you believe or suspect triggered your symptoms?
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
Known allergies to drugs, foods, environment etc - past and present
Chemical Sensitivities
FAMILY HISTORY
Major health problems in the family
LIFESTYLE
Describe your Home Situation, Work Situation, Hobbies/Pastimes, Recreational drugs usage
EXERCISE HABITS
Describe duration, intensity, frequency
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
0
1
2
3
4
5
6
7
8
9
10
Energy Level from 1 to 10 :
Morning
0
1
2
3
4
5
6
7
8
9
10
Mid-day
0
1
2
3
4
5
6
7
8
9
10
Afternoon
0
1
2
3
4
5
6
7
8
9
10
Evening
0
1
2
3
4
5
6
7
8
9
10
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
0
1
2
3
4
Dairy Products
0
1
2
3
4
Caffeine Drinks
0
1
2
3
4
White bread/pasta/ rice/noodles
0
1
2
3
4
Chicken
0
1
2
3
4
Fresh fruits
0
1
2
3
4
Table salt
0
1
2
3
4
Fish/seafood
0
1
2
3
4
Vegetables
0
1
2
3
4
Fried foods
0
1
2
3
4
Red meat
0
1
2
3
4
Green salads
0
1
2
3
4
How many glasses of water do you consume daily?
Do you consume alcohol? Yes/No. If, so how many standard drinks per week?
Do you smoke? Yes/ No. If so, how many cigarettes per day?
Foods that you have an aversion or sensitivity to:
CARBOHYDRATE METABOLISM
(Please check all that apply)
Sugar/Chocolate Cravings
Shakiness between meals
Irritability
Grazer
Emotional Eater
Sleepiness after eating
Hormonal/ Steroid treatments
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