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Health and Wellbeing Assessment
Please answer the questions to the best of your ability. This assessment will give us a general overview of your health currently with a large influence on gut health. It is a useful tool in helping to work on the areas that you feel need support to improve your overall health and well being. 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)
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Do you currently take medication for any diagnosed medical conditions?
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What is your first concern when it comes to your health? *
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Gut Do you experience flatulence more than once daily? Do you experience indigestion daily? Do you experience indigestion less than daily but more than once a week? Do you experience indigestion once a week or less? Do you get tired after eating? Do you have pain after eating? Do you have pain that is relieved by eating? Do you have pain that is relieved by a bowel motion? Do you have pain that is relieved by flatulence? Do you experience abdominal cramping? Do you experience low energy? Do you experience bloating more than once daily? Do you experience bloating less than once daily but more than once a week? Do you experience bloating once a week or less? Do you go more than one day without a motion? Do you go more than two days without a motion? Do you go two days or more without a motion? Do you have urgent bowel motions? Do you experience loose bowel motions more than once daily? Do you experience loose bowel motions once daily? Do you experience loose bowel motions once a week or less? Do you experience reflux or heartburn more than once daily? Do you experience reflux or heartburn once daily? Do you experience reflux or heartburn once a week or less? Have you had to take antacids in the past week? Do you take Panadol or ibuprofen more than once a month? Do you take Panadol or ibuprofen on an empty stomach? Do you use laxatives? Are you dependent on laxatives? Have you had any bariatric surgery? Do you react to certain foods? Do you prefer liquids/smoothies to whole food? Do you experience the symptoms of Irritable Bowel Syndrome? Does Irritable Bowel Syndrome affect your day to day life? Do you feel that food "sits" in your stomach? Do you ever have a sour taste in your mouth? Do you have low B12 status? Do you have low iron status? Microbiome Have you had antibiotics in the last 5 years? Do you take the oral contraceptive pill? Were you born via c-section? Do you eat less than 3 cups of vegetables per day? Do you experience high stress? Do you experience kidney infections? Do you experience bladder infections? Do you experience UTIs? Do you experience thrush or candida? Do you experience bacterial vaginosis? Have you tested positive to Giardia? Have you tested positive to Blastocystis hominis? Have you tested positive to Helicobacter pylori? Have you tested positive to Dientamoeba fragilis? Have you tested positive to any other parasites or bacteria? Do you drink alcohol weekly or more? Do you eat processed foods? Do you prefer liquids/smoothies to whole food? Do you have less than one bowel motion daily? Have you had Bali belly or food poisoning? Have you had an infection or illness where you've never felt quite right again? Liver & Elimination Are you easily angered or irritable? Do you wake between 1-3AM? Do you drink alcohol daily? Do you drink alcohol more than 3x a week? Do you drink more than 5 units of alcohol in one sitting? Do you eat processed foods? Do you eat a high carbohydrate diet? Do you eat a high protein diet? Do you have pale clay or orange/caramel coloured stools? Do your stools float? Do you experience acne? Do you drink coffee? Do you feel tired upon waking? Is your mood poor upon waking? Do you prefer not to eat breakfast? Do you have tenderness or pain around the bottom of your right rib cage? Have you been diagnosed with fatty liver disease? Do you smoke? Have you smoked in the last five years? Do you experience skin rashes or reactions? Do you take medication regularly? Do you have less than one bowel motion daily? Do you drink less than 1L of water daily? Do you get headaches? Immunity Do you experience frequent infections or illness? Have you had antibiotics in the last year? Have you had more than one round of antibiotics in any given year? Do you smoke? Have you smoked in the last five years? Do you experience skin rashes or reactions? Do you react to certain foods? Do you suffer from allergies? Do you experience hayfever? Do you react to any other environmental factors (eg rain, grass, fibres)? Have you been diagnosed with autoimmunity? Do you experience fatigue or poor energy? Do you experience muscle aches and pains? Do you experience joint pain? Have you ever had Glandular Fever? Have you ever had Ross River Virus? Do you have white spots on your nails? Do you have swollen or painful glands? Have you been sick in the last month? Are you on immunodepressant medication (eg. Cyclosporin)? Were you born via c-section? Do you experience recurrent vaginal infections, like thrush or bacterial vaginosis? Have you received a positive HPV result in a pap smear? Adrenals Do you have irregular eating habits? Do you skip any meals because you’re too busy? Do you often go long periods without eating? Do you experience high stress in your job? Do you experience high stress in your day to day life? Do you experience high stress in your home life? Do you experience high stress in your relationships? Do you have high or low blood pressure? Do you feel dizzy when you get up quickly? Are you likely to get sick when you go on holidays? Do you get sick frequently? Do you sometimes feel like your body is tired but your mind is wired? Do you experience energy fluctuations throughout the day? Do you experience fatigue at 10AM? Do you experience fatigue at 12PM? Do you experience fatigue between 3-4PM? Do you fall asleep on the couch when you get home? Do you get a “second wind” at night? Do you drink caffeine daily? Do you have irregular menstrual cycles, often being longer than 32 days? Do you sometimes miss a period for no reason? Do you have a busy life? Do you crave salt or sugar? Is it difficult for you to fall asleep? Do you wake more than once during the night? If you wake during the night, is it difficult to fall back asleep? Do you experience mental chatter or a busy mind? Do you use your phone, iPad or computer an hour before bed? Do you feel like you have no time for yourself? Do you get less than 5 minutes of direct sun exposure in the morning? Do you feel tired after exercising? Do you feel tired upon waking? Does it take you longer than an hour to naturally wake up? Do you only feel refreshed after coffee or a shower? Do you have dark circles around your eyes? Do you get less than 4 hours sleep a night? Are you a light sleeper? Do you eat sugar daily? Do you smoke? Have you smoked in the last 5 years? Do you have high expectations of yourself? Do you experience difficulty concentrating? Stress Do you have difficulty sleeping? Do you experience mental chatter or a busy mind? Do you get heart palpitations or a racing heart? Do you feel nervous and fidgety? Do you feel unmotivated or lethargic? Do you experience high stress in your job? Do you experience high stress in your day to day life? Do you experience high stress in your home life? Do you experience high stress in your relationships? Have you had high physical or emotional stress in the past five years? In the last two years, have you been separated or divorced? In the last two years, have you lost someone? In the last two years, have you had a serious health diagnosis? In the last two years, have you had a relationship breakdown? In the last two years, have you had extreme financial hardship? Do you feel that you have a lot of nervous energy? Do you feel overwhelmed frequently? Do you experience shortness of breath? Do you experience depression? Do you have a lot of negative self-talk? Do you feel that you have no purpose? Do you feel unhappy in your day to day life? Are you the person people go to with their problems? Do you worry about things that you cannot control? Do you drink alcohol to calm your mind or your body? Do you have a child with special needs? Are you a carer for anyone? Do you have children under the age of 18? Do you have children under the age of 4? Do you experience anxiety or panic attacks? Do you experience anxiety or panic attacks more than once a week? Do you experience chronic pain? Do you have high expectations of yourself and/or others? When you poke your tongue out, can you see teeth indentations on the sides? When you poke your tongue out, does it quiver? Do you find it difficult to trust or rely on others? Do you worry about your health? Do you worry about your future? Do you feel that your support network is lacking? Do you find it difficult to wind down? Do you experience tension headaches? Do you have tight shoulders? Do you care for others before yourself? Toxic Load Please note where chemicals are referred to in this question, it is referring only to non-natural products (including cleaning products, skincare, haircare) that contain sulfates, petroleums, etc. If you use natural based products in your home already, please do not tick yes to these questions. Are you a smoker? Have you smoked in the last five years? Do you use recreational substances once a month or more? Do you drink alcohol daily? Do you drink alcohol more than 3x a week? Do you drink more than 5 units of alcohol in one sitting? Are you required to use any harsh chemicals at work (eg hair products, cleaning, nail products)? Do you use any chemicals at work that require you to use PPE? Are you a hairdresser? Do you use chemical cleaning products at home? Do you have skin contact with cleaning chemicals at home daily? Do you have skin contact with bleach or something similar once a month or more? Do you use skin products that contain chemicals? Do you use hair (shampoo, conditioner, treatments) products that contain chemicals? Do you use make up that contains chemicals? Do you use deodorant that contains chemicals? Do you have tattoos? Do you microwave your food? Do you use plastic containers? Do you heat your food in plastic containers? Do you heat your food in plastic containers that are not microwave safe? Do you use plastic water bottles? Do you use plastic water bottles that are not BPA free? Do you cook with aluminium? Do you cook with oven safe bags? Do you use a plastic kettle? Do you eat vegetables that are not organic? Do you eat vegetables that are not spray-free? Do you eat meat that is not organic? Do you eat bacon that is not nitrate-free? Do you eat ham that is not nitrate-free? Do you eat smoked meats (eg salmon, kabana, salami)? Do you eat smoked meats more than once a week? Do you eat smoked meats more than three times a week? Do you eat hot food out of takeaway containers? Do you drink takeaway coffee with plastic lids? Do you live within 3km of a petrol station? Do you live within 1km of a petrol station? Do you drink non-filtered water? Do you see mould growing on items around your workplace? Do you see mould growing on items inside your home? Do you have carpet at home that is more than 10 years old? Do you have carpet at work that is more than 10 years old? Do you get your hair coloured or chemically treated in any way? Do you get any cosmetic enhancements? Have you had breast implants? Do you take medication regularly? Do you have less than one bowel motion daily? Do you drink less than 1L of water daily? Did you grow up in a mining town? Do you currently live or work in a mining area? Have you tested positive for heavy metal toxicity in the past? Thyroid Do you have problems with your short-term memory? Do you struggle to lose weight? Do you gain weight quickly? Do you have heavy periods? Do you get clotting during your period that’s larger than a 5c coin? Do you have cycles that are longer than 30 days? Do you have dry, cracked heels? Do you feel the cold easily? Do you experience high stress in your job? Do you experience high stress in your home life? Do you experience high stress in your relationships? Have you had high physical or emotional stress in the last five years? Have you been diagnosed with a thyroid condition (eg. Hashimoto’s, Grave’s, subclinical hypothyroid) Do you experience heart palpitations? Do you feel tightness, constriction or puffiness around your lower throat? Do you have a hoarse voice? Do you experience fatigue? Do you experience hair loss or thinning hair? Do you nap during the day, given the chance? Do you smoke? Have you smoked in the last 5 years? Do you have dry or itchy skin? Do you experience depression or low mood? Are you anaemic (iron deficient)? Hormones Are you on any form of contraceptive device (eg Implanon, pill, IUD-Mirena)? Do you have menstrual cycles lasting longer than 40 days? Do you have menstrual cycles lasting longer than 35 days? Do you have menstrual cycles lasting longer than 30 days? Do you have menstrual cycles lasting less than 20 days? Do you have breakthrough bleeding in between periods? Do you have painful periods that mean you miss work/life activities? Do you experience pain that makes you feel sick? Do you regularly experience loose bowel motions during or before your period? Do you experience clotting during your period? Do you have sore or tender breasts before your period? Do you have sore or tender breasts during your period? Do you experience ovulation pain? Have you been on the oral contraceptive pill? Do you have heavy periods? Do you have hair on your nipples? Do you experience acne before your period starts? Do you experience acne halfway through your cycle? Do you experience acne during your period? Do you experience acne in the week after your period ends? Does your period last less than 3 days? Does your period last longer than 7 days? Do you have facial hair? Do you experience strong cravings leading up to your period? Are you irritable before your period? Are you angry before your period? Are you sad before your period? Are you lethargic before your period? Do you think you have low libido? Have you experienced infertility or unexplained difficulty conceiving? Do you have problems with your short-term memory? Do you experience hot flushes? Do you experience mood swings? Do you have fluid retention or water weight? Do you have dry or itchy skin? Have you smoked in the last 5 years? Do you have insulin sensitivity? Do you have elevated blood glucose levels?
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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