Health Questionnaire

Full Name

Date of Birth

Age

Gender GenderMaleFemale

Address

Phone Number

Email Address

Emergency Contact Name:

Emergency Contact Phone:

Primary concern or reason for seeking wholistic care today:

How long have you been experiencing this issue?

Do you have any of the following chronic conditions? (Please check all that apply) Do you have any of the following chronic conditions? (Please check all that apply) Hypertension (high blood pressure) Diabetes (Type 1 / Type 2) Asthma Heart disease Stroke Arthritis Chronic pain (back, joints, etc.) Chronic Sinusitis Chronic ear infections Chronic UTI ( Urinary Tract Infections ) Cancer Kidney disease Liver disease Respiratory disorders (COPD, etc.) Seizures Depression / Anxiety Sleep apnea None

If you ticked Cancer, please specify

Other (please specify):

Have you ever been hospitalised? Have you ever been hospitalised? Yes No

If yes, please list the reason(s) for hospitalisation and date(s):

Have you ever had surgery? (medical or beauty related) Have you ever had surgery? (medical or beauty related) Yes No

If yes, please list type of surgery and date(s):

Do you have any allergies? Do you have any allergies? Yes No

If yes, please list:

Are you currently taking any medications? Are you currently taking any medications? Yes No

If yes, please list all medications, including dosage:

Do you use any over-the-counter medications or supplements? Do you use any over-the-counter medications or supplements? Yes No

If yes, please list

Do you have a history of mental health conditions? Do you have a history of mental health conditions? Yes No

If yes, please specify:

Has anyone in your family had the following conditions? (Please check all that apply) Has anyone in your family had the following conditions? (Please check all that apply) Heart disease Stroke Hypertension (high blood pressure) Diabetes Cancer (please specify type): _____________ Kidney disease Mental health disorders (anxiety, depression, etc.) Autoimmune disorders Genetic disorders None

If you ticked Cancer, please specify

Other (please specify):

In the last Three Years have you taken antibiotics? In the last Three Years have you taken antibiotics? Yes No

If Yes, Please indicate period and Dosage of the Antibiotics

2024: What was the Dosage taken per day 500 or 1000mg

2023/22: What was the Dosage taken per day 500 or 1000mg

Lifestyle and Social History: Do you smoke? Lifestyle and Social History: Do you smoke? Yes No

If yes, how many cigarettes per day?

How many years have you been smoking?

Have you ever tried to quit? Have you ever tried to quit? Yes No

Lifestyle and Social History: Do you drink alcohol? Lifestyle and Social History: Do you drink alcohol? Yes No

If yes, how often? If yes, how often? Daily Weekly Occasionally

How many drinks per week?

Do you drink coffee, tea or fizzy drinks? Do you drink coffee, tea or fizzy drinks? Once a Day Twice a Day More than Three times a day Occasionally None

If yes, please specify:

Do you follow a specific diet (e.g., vegetarian, vegan, low-carb, etc.)? Do you follow a specific diet (e.g., vegetarian, vegan, low-carb, etc.)? Yes No

How would you describe a typical day of your diet? (e.g., breackfast, lunch etc)

Do you have any dietary restrictions? Do you have any dietary restrictions? Yes No

If yes, please specify:

Do you have desserts Daily? Do you have desserts Daily? Yes No

How many times a day? List examples of dessert choices

Do you take any Probiotics? Do you take any Probiotics? Yes No

If yes, what is the strength, how long ?

Do you take any vitamins? Do you take any vitamins? Yes No

If yes, what are they? What are the dosages? How long?

Do you exercise regularly? Do you exercise regularly? Yes No

If yes, how often and what type of exercise?

What is your current employment status? What is your current employment status? Employed full-time Employed part-time Student Unemployed Retired