HEALTH EVALUATION FORMStrictly Confidential

Please complete this form carefully. The information provided will help us build a personalised healthcare programme for you.

Biographical DetailsDate:      Referring Practitioner:      Name:       Male Female DOB:       Age:      Marital Status: Single Partnered Married Separated Divorced Widowed

Number of Children:      

Email Address:      Phone: (Home)       (Work)       (Mobile)      Mailing Address:      Current Occupation:       Past Occupations:      

Please do not take any supplements for 2 meals prior to your first evaluation

ClinicalWeight (kg):       Height (cm):       Blood Pressure:       Pulse:      

Chief ConcernsPlease rank your current health concerns and rate their severity (on a scale of 1 – 10, 10 being most severe)1.       Scale (1-10):      2.       Scale (1-10):      3.       Scale (1-10):      4.       Scale (1-10):      

Health HistoryPlease provide a detailed timeline of your personal health history, from childhood. Include all major traumas (physical and emotional), operations and illnesses, the age you were and what changes you experienced in your health.                                                                  

Other TherapiesIf you have tried therapies to help these issues in the past, what was successful and what was not?     

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MedicationsPlease list any medications you are currently taking, including self-prescribed medications such as Panadol etc.Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      

SupplementsPlease list supplements that you currently take and include brand names.Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      Name:       Length of Use:       Dose:      

Health OverviewEnergyPlease rate your current energy level (on a scale of 1-10, 10 being the highest energy)

Scale (1-10):      

Does your energy change through the day and if so how does the scale change:

Morning Scale (1-10):      

Other:       Afternoon

Scale (1-10):      

      Evening Scale (1-10):      SleepHow is your sleep? Restful Restless Hard to get to sleep Wake often Get up during night Bad dreamsOther symptoms?      What time do you usually go to sleep?       How many hours per night?      ExerciseWhat kind of exercise do you do?      How often do you exercise?      For how long at a time?      StressPlease rate your current stress level (scale of 1-10, 10 being highest) Scale (1-10):      What is the main reason for your stress?      What steps are you taking to reduce your stress level?      EmotionalPlease list any psychological or emotional issues that you are currently experiencing:      How would you describe your overall mood?      

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Health Overview ContinuedEyes & Ears

Do you wear glasses Contact lenses Had laser eye surgery Cataracts Glaucoma Poor night vision Wear hearing aids Have impaired hearing Poor night vision Tinnitus

Other?      

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Please explain:      SunlightHours of natural sunlight you receive daily outside?      

Hours of sunlight you receive daily through windows?      

Hours spent daily under fluorescent lights?      UrinationHow are your daily urinations? 2-3 hours Too frequent Sense of urgency Too small amount

Too large amount Burning Dribbling Up several times at night Other symptoms?      DigestionHow is your digestion? Adequate Poor Acid reflux Burp often Gas Bloating Burning/pain in stomach Pain before bowel movement Nausea before bowel movementOther symptoms?      BowelsEliminations per day: One Two Three Skips days Every 2-3 days Once a weekAmount: Normal Too little Too large Other: Lots of mucous Lots of gas Foul smellConsistency: Easy to pass Difficult to pass Formed Too hard Falls apart in toilet Floats Soft LooseColour: Dark brown Light brown Black Greenish brown Whitish BloodOther symptoms?      

Women OnlyAre you pregnant or breastfeeding? No

Date of last menstrual period:      

Are your periods regular? Yes No Cycle Length:       Menstrual duration (days):      

Have you had a hysterectomy? Yes No How many children have you delivered?      Are you going through menopause? No

What is your current form of birth control?      

Had an episiotomy or a C-section? Current or previous reproductive disorder?      Had an epidural? Yes No Have you struggled with fertility/miscarriage? Yes

No

Are you experiencing any of the following? Hot flashes Night Sweats Drop in libido Painful periods Cramping Cysts Fibroids PMS Difficulty losing weight Insomnia

Other symptoms?      

Men OnlyHave you experienced a drop in muscular strength, drive or libido? Yes NoDo you have difficulty urinating or have an enlarged prostate? Yes NoIf you answered yes, please explain further:      

PetsDo you have any pets? Yes No

If so, what kind and how many?      

Is it allowed in all areas of the house?      

On your bed?      

What do you feed your pet(s)?      

Do you frequently de-worm your pets?      

If so how often:      

Chemical ExposurePersonal Care & Household Products (please indicate products & brands)Perfume/Cologne:       Hair Product:       Shampoo:       Cleanser:      

Hand/Body Lotion:       Toothpaste:       Make-up:       Hair Dye:      

Nail Polish Remover:       Deodorant:       Moisturiser:       Soap:      

Shave Cream:       Conditioner:       Nail Polish:       Other:      

Other chemical exposure from personal care products:      Dishwashing:       Air Freshener:       Fly Spray:       Paint:      

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Laundry Soap:       Glass Cleaner:       Pesticides:       Other:      

All-Purpose:       Insecticides:       Fertilisers:       Other:      

Toilet Cleaner:       Herbicides:       Bleach:       Other:      

Other chemical exposure (from garden, work, art chemicals, etc):      

Electromagnetic Exposure – How many hours per day do you spend...

Watching TV:       Computer use:      On landline phone:      

On mobile phone:      

Wearing a pager:      Wearing a headset:      

Wearing a watch:      Wearing hearing aids:      

Travelling by vehicle:       How often do you use a microwave oven?      

When you sleep, is your head within 3 metres of a plug-in clock (such as on a night stand)?      Please tick any of the following that you use: Microwave oven Electric stove Gas stove Electric heater

Electric blanket Water bed Water purifier (brand:       ) Shower Filter (for chlorine protection) Dehumidifier -- Cookware Stainless steel Teflon-coated Aluminium Cast iron Glass Silicone

Body Systems Tick the individual symptoms being experienced and indicate 1 to 5 degree of severity. 5 being very severe.

Severity

LY I experience recurrent infections, sinusitis, post nasal drip or swollen lymph nodes... LU I experience recurrent respiratory infections, coughs, bronchitis, pneumonia, asthma... LI I experience bouts of diarrhoea, constipation, gas, bloating... NE I experience irritability, nervousness, trembling, anxiety, memory problems... CI I have cold fingers/toes, blood pressure problems, varicose veins, circulation issues... AL I react to pollens, moulds, foods, seasonal irritants, perfumes, animal dander... TH I have a slow metabolism, am always hungry, have low energy at specific times of day... TW I have mood swings, problems sleeping, am always cold, have chemical imbalances... HT I experience heart palpitations, pain in my chest, irregular heart beat... SI I have recurrent yeast infections, frequent antibiotic use, poor diet... JT I experience joint pain, stiffness, inflammation in my body... PA I have diabetes, blood sugar issues, irritability, shaking if I skip a meal... SP I experience chronic fatigue, recurring infections, get sick easily... LV I experience high cholesterol, wake up between 2-4am, indigestion after fatty meals... SK I have rashes, dryness or cracking, scaly patches, eczema, acne, psoriasis... GD I struggle with impotence, libido, miscarriages, sterility... UB I have recurring urinary tract infections, painful urination, leaking, urinary frequency... KI I experience swelling, gout, pain in the lower back, history of kidney stones...

Surgeries/InjuriesWhat surgeries, operations, traumas, car accidents, etc have you had?          a) Have you ever had full body anaesthesia (ie. To remove tonsils, wisdom teeth, etc)?      b) Do you have any surgical implants (breast implants, metal pins, plates, clamps etc)?      c) Have you had elective surgery (rhinoplasty, tummy tuck, liposuction, mole removal, etc)?      d) Do you have pierced ears or other body piercings?      e) Do you have any tattoos?      

ScarsPlease describe any scars on your body (major and minor ones)          

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Please indicate on the charts below all surgeries, operations, piercings, tattoos, traumas, and accidents you have had.

Note: Commonly forgotten scars for men are circumcision/vasectomy and for women episiotomy scars.

Left Right

Personal Health Goals1. How important is your health to you on a scale of 1-10 (10 being highest)?      2. What is most important to you in a health practitioner team?      3. How much confidence do you have in your body’s ability to heal itself given the right nutrients & natural therapies? On a scale of 1-10 (10 being high)?      4. How much confidence do you have in medical drugs, on a scale of 1-10 (1= low; 10= high confidence)?      5. What are your specific health goals? (What do you really want?)           6. How far are you willing to commit to achieve your health goals? (Please be honest)

Don’t really want to change much Willing to change some Willing to change a reasonable amount Willing to do whatever it takes

7. How much money do you spend per month on your health?      

8. How long do you want to live? (Check all that apply) Age 60-70 only if my significant other is still alive also as long as I’m healthy Age 70-80 as long as I have been granted it’s already enough Age 80-90 until I complete my mission (purpose) on earth forever Age 90-100 Age 100+

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Doshas – Vata/Pitta/KaphaEnergy Imbalances - Please tick the symptoms which you are experiencing regularly...VATA – Please indicate total # of checks (     )

Worried Fainting spells, dizziness Low back pain or menstrual cramping Weakness Fatigue, poor stamina Agitated mind, difficulty concentrating Indecisive Generalised aches, pains Constipation, intestinal gas, bloating Nail biting Very sensitive to cold Antsy or hyperactive behaviour Shy, insecure Dry, sore throat, dry eyes Arthritis, stiff & painful joints Heart palpitations Tired, yet can’t relax Losing weight, underweight Dry, rough, flaky skin Anxious, fearful, nervous Insomnia, wake up at night Headaches

PITTA – Please indicate total # of checks (     ) Boils Argumentative, bossy Very sensitive to heat, hot flashes Impatient Fevers, night sweats Weakness due to low blood sugar Skin rashes Sour body odour Bad breath, bitter taste in mouth Angry, irritable Frustrated, wilful Excessive hunger or thirst Inflammation Hostile, destructive Disturbing, violent dreams Flushed face Bossy, controlling Critical of self and others Blood-shot eyes Diarrhoea, loose stools Acidity, heartburn, ulcer Acne, rosacea

KAPHA – Please indicate total # of checks (     ) Nausea Slow to comprehend Mucus & congestion in sinuses/nose Diabetes Pale, cool, clammy skin Greedy, possessive, materialistic Slow to react Procrastinating, lethargy Clingy, hanging onto people/ideas Groggy all day Sluggish dull thinking Body & limbs feel heavy, swollen High cholesterol Weight gain, obesity Very tired in morning, hard to get up Allergies, hayfever Water retention, swelling Mucus & congestion in throat/chest Apathetic, no ambition Depressed, sad, overly sensitive Sluggish digestion, mucus in stools Sleeping too much

Dental HealthWhen was your last dental appointment and what treatments were done?      Do you have any dental concerns?      Do you currently have or have you ever had any amalgam/silver fillings?      Do either of your parents have amalgam/silver fillings?      Do you experience any of the following? Receding gums Bleeding gums Mouth ulcers

Tooth pain Bad breathOther symptoms?      

Please fill out the dental chart below to the best of your knowledge. Use the example chart as a guideline:

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Toxic BurdenSmokingDo you currently smoke?      

If yes, how much? How long have you smoked?      

Do you frequently breathe second-hand smoke from others who are smoking (either at home or work)?      AlcoholDo you drink alcohol: Daily Weekly Monthly Not at allWhat do you drink and how much?      Recreational Drugs - This is strictly confidential informationDo you currently use recreational drugs? Marijuana Ecstasy Cocaine Methamphetamine

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Heroin Uppers DownersOthers?      Have you used recreational drugs in the past?      

If yes, what and for how long?      

BACTERIA Yellow/green discharge Fever gets worse with time Symptoms persist longer than 10-14 days Focal area of illness (sinuses, lungs, throat, etc) I am concerned about this group. State why ►

VIRUSES Clear discharge Low-grade fevers/chills Body-wide aches/fatigue History of chronic viral infection (EBV, HPV, Herpes, HIV, etc) I am concerned about this group. State why ►

MOULD/FUNGUS Frequent antibiotic use Fungal rashes/eczema/psoriasis/yeast infections White, coated tongue Strong cravings for sugars and starches I am concerned about this group. State why ►

HEAVY METALS Exposure through vaccinations/job Currently have silver fillings/recently had them removed Memory difficulties Tremors/Alzheimer’s/Parkinson’s I am concerned about this group. State why ►

CHEMICALS Use commercial cleaning products Chemical exposure at home or work (hair salon, nail salon,

etc) Use commercial personal care products Currently smoke or have been exposed to smoke I am concerned about this group. State why ►

PESTICIDES Eat non-organic produce and animal products Use fertiliser and pesticides in the garden Drink/bathe in unfiltered tap water Pesticide exposure through occupation I am concerned about this group. State why ►

PARASITES History of digestive upset Bloating/gas Itching skin, especially at night Irritable bowel/Crohn’s/Celiac I am concerned about this group. State why ►

DetoxificationPrevious Cleansing Experience - Please check the organs which you have cleansed in this past year.

Colon Liver/Gallbladder Kidneys Lymph/Whole BodyWhat benefits or difficulties did you experience?           

Are you ready to detox?Detoxification requires energy of the body. Please check the following criteria that applies:

I am not pregnant or breastfeeding I am having a daily bowel movement I am willing to stay hydrated (daily quantity of good quality water: weight x 0.03 = litres of water) I can handle temporary reduction in energy or short-term flare in my symptoms during detoxification I am willing to measure my 1st morning urinary pH to make sure that my pH is between 6.4 and 7.2

Food & DietYour Typical Diet - Please complete the following food diary in as much detail as possible

Day 1 Day 2 Day 3

Breakfast

Time:       Time:       Time:      

Food(s):       Food(s):       Food(s):      

Morning tea Time:       Time:       Time:      

Food(s):       Food(s):       Food(s):      8

Lunch

Time:       Time:       Time:      

Food(s):       Food(s):       Food(s):      

Afternoon tea

Time:       Time:       Time:      

Food(s):       Food(s):       Food(s):      

Dinner

Time:       Time:       Time:      

Food(s):       Food(s):       Food(s):      

Dessert/ Evening snack

Time:       Time:       Time:      

Food(s):       Food(s):       Food(s):      

Beverages

                 

Meal PreparationDo you prepare meals at home?       Do you share cooking duties? Who with?      

How many meals do you eat out at restaurants per week? Breakfast (     ), Lunch (     ) & Dinner (     )Do you have a microwave oven?       How often do you use it?      Do you have a blender?       Do you have a juicer?      

HydrationHow many glasses (or litres) of water do you drink daily?      Which type of water do you drink: Tap Filtered Bottled Tank Bore SpringHow many of the following diuretics do you drink daily? Coffee (     ), Caffeinated Drinks (     ), Alcohol (     )

Food ChoicesPlease check each type of food that you eat once a week or morePre-made foods: Canned Boxed cereals Frozen dinners Bottled juices Take-out foodsRed meat: Beef Pork Lamb Commercially grown Organic Free range (brand:       )Chicken: Commercially grown Free-range Organic (brand:       )Fish: Canned tuna Canned salmon Canned sardines Fresh fish Frozen fish Shellfish (type:       )Fresh vegetables & fruit: Commercially grown (store-bought) Organically grown (store-bought) Organically grown (direct from farmer) Spray-freeWhole grains & legumes (beans): Commercially grown (store-bought) Organically grown (store-bought)

Organically grown (direct from farmer) Spray-freeEggs: Commercial eggs (store-bought) Naturally grown eggs Free-range Organic

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Butter: Commercial butter (store-bought) Organic butter (store-bought) Milk: Commercial milk Organic pasteurised milk Raw whole milk Goat’s milk Other (      )Cheese: Commercial cheese Organic cheese (store-bought) Raw cheeses

Types of cheese you regularly eat (      )Condiments: Commercial salt and/or pepper Sea salt (brand:       ) Artificial sweeteners (Equal, Splenda, Aspartame, etc) Sauces (      ) Vinegars (      ) Oils (      )

Food StressorsPlease indicate how many times per week you consume the following foods:Coffee (including decaf)    Fried foods    Cow’s milk    Bread   Black tea, green tea, white tea    Fast food    Yoghurt    Crackers   

Soft drinks (colas, etc)    Potato or corn chips    Ice cream    Bagels   

Drinks with nutrasweet/aspartame    Roasted nuts    Cottage cheese    Buns   Alcohol (wine, beer, etc)    Mayonnaise    Sour cream    Pasta   Chocolate    Margarine    Cream cheese    Muffins   Candy, pastries, sweets    Peanut butter    Cheese    Cookies, cakes   Chutney    Snack bars    Dips and spreads    Pies   

Food SensitivitiesPlease indicate the foods to which you know that you have sensitivity:

Casein Corn Dairy Egg Gluten Peanuts Shellfish Soy WheatOther:           

Diet DescriptionCheck all that apply (please be honest)

Mostly eat out (fast food) Mostly eat out (but try to eat healthier items) Eat whatever is available Occasional binges Would never reduce meat Vegetarian Vegan Eat a lot of fresh food (no cans, boxes, packets) Eat mostly organic Eat a lot of raw food Mostly homemade meals In transition to eating better

Other:           

Weight ManagementDo you want to lose weight?       If so, how much?      Please list any weight loss programs you have tried and rate them out of 10 (1 = terrible, 10 = terrific)...               

Your InsightsDo you have any insights regarding the root cause of your issues (related symptoms, emotional events, injuries or trauma that happened at the same time of onset... etc)? Is there anything else that we haven’t asked about that you think is important?                                        

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Empowerment TopicsWhich of the following topics do you feel you could most benefit from? Tick all that apply...

Grief/Loss Prosperity Health/Body Relationships New Direction & Resolution Self-Esteem Personal Power Spirituality

Other:      

Your Wheel of Life

Please circle your current level of satisfaction in each area of your life. 0=horrible, 5=okay, 10=terrific!

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