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Health Questionnaire
It is essential to see the driving factors behind feeling unwell. This questionnaire will allow you to see what systems in your body are challenged or compromised at the moment, which may be contributing to your current health concerns. Please select any symptoms that you experience. You will receive a copy of your State of Health graph, as will the clinic providing this questionnaire, so that you may discuss your health concerns with a professional. Your information is kept confidential at all times. Note: All fields marked with a red asterix are required fields.*

Your Details
Name	* Required
Age	* RequiredRequired
Email	* RequiredRequired
Phone (if wanting to be contacted by the Clinic)
Diagnosed Medical Conditions (if applicable)
Invalid
Do you currently take medication for any diagnosed medical conditions?
Invalid
What is your first concern when it comes to your health? *
RequiredInvalid
Please list what allergies you have:

Please list diagnosed autoimmune diseases:

Section One Struggle to lose weight Low sex drive Irregular menstrual cycles Feel the cold easily Painful periods (requiring pain relief or medication) Feel unmotivated Sore or tender breasts Fatigue Heavy periods with clotting Mood swings Infertility or unexplained difficulty conceiving Fluid retention or water weight Poor short-term memory Difficulty concentrating Tired upon waking Dry or itchy skin Low or high blood pressure Irregular eating habits (less than 3x daily or more than 6x daily) Frequent infections or illness High emotional or physical stress in the past 5 years Difficulty sleeping (getting to sleep/staying asleep) Anxiety or panic attacks Experience hot flushes Experience depression or low mood Section Two Frequent infections or illness Antibiotics in the last 2 years Smoker currently or less than 5 years ago Do you react to certain foods Do you eat wheat Do you drink cow’s milk Skin rashes Poor energy Do you suffer from allergies Have you been diagnosed with any autoimmune diseases Do you experience asthma or hayfever Were you not born naturally and/or breastfed Section Three Smoker currently or less than 5 years ago Joint pain Do you have osteoarthritis Chronic pain Do you eat processed foods (including bread, biscuits, sauces) Do you consume sugar Do you drink coffee Do you drink cow’s milk Allergies/sensitivities to foods/things in the environment Less than one bowel movement daily Headaches Have you been diagnosed with any autoimmune diseases Drink less than 1.5L of unflavoured/unsweetened water daily Do you sit for longer than 1 hour at a time Do you drink softdrink Poor energy Section Four Do you drink cow’s milk Do you eat wheat Have you suffered from thrush in the past month Abnormal stools (diarrhoea/constipation/urgent) Flatulence Burping Indigestion pain or pain after eating Reflux or heartburn Poor energy Intolerances to food Bloating Do you take panadol or ibuprofen Drink alcohol 1x weekly or more Antibiotics in the last 2 years Section Five Difficulty sleeping (getting to sleep/staying asleep) History of addiction (including alcohol/cigarettes/food/drugs) Feel unmotivated Do you feel unhappy in your day-to-day life Do you experience mental chatter or a racing mind High emotional or physical stress in the past 5 years Heart palpitations or a racing heart Shortness of breath Nervousness or fidgeting Depression or anxiety Section Six Do you drink coffee Drink alcohol 1x weekly or more Tired upon waking Easily angered / irritable Tenderness or pain around upper right ribs Pale clay or orange/caramel coloured or floating stools Do you eat processed foods (including bread, biscuits, sauces) Do you wake between 1-3AM Do you experience indigestion or feel your digestion is a little sluggish Do you have to have large amounts of medication/alcohol to feel their effects
By submitting your information, you consent to the way your information is used, as set out here, and in the Terms and Conditions & Privacy Policy on the clinic’s website. Your Health Report is for educational purposes only.
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Section One

Section Two

Section Three

Section Four

Section Five

Section Six