YourHealttiCONFIDENTIAL PATIENT QUESTIONNAIRE

Please complete the following questionnaire. Your response remains confidential andwill provideinformation for your practitioner to use in your assessmentand treatment.

I V . r A . t t D t 11/03/2009 T 12 20PMDEP ITrac I loner: r mmanue anpa IS; ������ men ae: rne:Title Mr<S Date ofBirth 31/12/1952

First / Second Names ANDJELKA Sumame KRSMANOVIC

Home Address 19 Val/ingby Av

SuburblTown J1 t6b1t rl1lfM I State IJ ����� IPostcode ':1170Home: ( {))..) q���� -OLyoo : IWork: ( ) IMobile: ���������Medicare Number (exp. ) Private Health Fund IJO.

EmailAddress dvo.Op� (ul-a.. ,1-1Height(em) 1:::f-.<J IWeight (kg) ::t-G Would you like tosubscribe to ouronlinenewsletter?@ NO

Next ofKin 'JI\<;;,W'J'<- IRelationsh ip 'Dl\\J€Ml"\-;----L ITelephone No: 0--\0\ ���� g-iDHowdid you hear about YourHealth? Please circle thecategory below.

Advertisement Article Brachure-Flyer-Poster Direct Mail Email NewsletterJ

Expo-Conference ( �������������� Gift Voucher-Prize Orion Corporate Pharmacy-Health foodCollea Health store

Practitioner referral Seminar TV-Radio interview Walk-by-Signage Website

Other (pleasespecify)

GENERAL DETAILSPlease listthe main problems you are experiencing and/or reasons forthis appointment.

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What doyou believe the problem may bedueto?

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YourHealtt}MIND Y, Poor Memory Total

3 Confusion poor comprehension� Poor Concentrationt Poor physical co ordinationzr Difficulty inmaking decisionso Stuttering or stammering /So Slurred speechJ:} Leaminq disabilities -

MOUTH JTHROAT o Chronic coughing Totalo Gagging, frequent need toclear throatfi Sore throat, hoarseness, loss of voice 4Swollen ordiscoloured tongue gums, lipso Canker sores

" ....NOSE _1 Stuffy nose .-J3r_ee.d �����e \� � Total

� Sinus problems:2 Hay feveru Sneezing attacks 3Q Excessive mucus formation

SKIN o Acne Total.L: Hives, rashes,ordry skinu. Hair loss-fi Flushing or hot flushes /3Excessive sweating

WEIGHT <0 Binge eating Jdrinking Total.3 Craving certain foods

J...1IJji Excessive weighto Compulsive eating

-9:!f. Water retentionn Underweight-

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OTHER -=l- Frequent illness Total12 Frequentor urgent urination3..- Genital itch or discharge

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GRAND TOTAL-

COMMENTS:

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YourHealttl®General Acknowledgement and Consent Form

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understand that some of the diagnostic tests, treatments and products administered bypractitioners at YourHealth Manly may be outside the parameters of conventional medicine inAustral ia. They fall into the category of Natural or Complementary Medicine. I understand thatthese diagnostic tests, treatments and products are supported by empirica l knowledge, aresafe, are widely and successfully used by Integrative Medical practitioners in centres inAustra lia and overseas, and are only prescribed with utmost care. Some diagnostic tests andtreatments offered at YourHealth centres are not covered by Medicare or private healthinsurance funds . All YourHealth practitioners are members and active participants of theirrespective professional Colleges and Associations.

I am attending YourHealth Manly of my own free will and consent and exercise my right todiscuss and choose any useful and suitable treatment(s) made available to me. I understandthat YourHealth practitioners may recommend and dispense items that are yet to be regulatedby the Therapeutic Goods Administration (TGA), should the practitioner deem that suchproducts or treatments are in my best interest. If there are any risks associated with usingunregulated products or treatments, the YourHealth practitioner(s) will make me fully aware ofthose risks and provide me with sufficient information to make an informed decision.

Signed,

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Signature: . Signature: (f7/Zt�� ���

Patient's Name: !bJ:p}fLJtk- //;t-mMtfWitness'sName:���

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YourHealttlWhat kind oftreatment(s) have you tried for the problem(s) listed above?Please detail any relevant testing orinvestigations andbring relevant copies withyou toyour consultation.

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When was the last time you felt truly well?

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What do you expect from your consultation today?

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What doyou think can helpyou?

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PAST MEDICAL HISTORYPlease circle as appropriate.

IIInesslMedical Problem Present Past

HeartNascular Disorder YES YES

Blood disorder YES YES

High blood pressure ���� YES

Cancer YES YES

Arthritis YES YES

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YourHealth®PA-Si

Diabetes YES YES

Liver disease YES YES

Kidneydisease YES YES

Asthma YES YES

Epilepsy YES YES� "'"',

Hepatitis Pr · YES cYGlandular fever YES YES

Dysentery YES YES

Sexually Transmitted Diseases YES YESPleasespecify.Other conditions

��������I 0ES) (YES)Please specify. oiSEflr6B""

Operations ��� ����� �������� l(rn ·/ (-!f/ 9 YESINO CfulNOPlease specify. ����������� os is 1..C{ IS0Pregnancies it '

J'1 '7'LtI /qCl-6" YES/NO @ NOl or n ·, I 'U,? .Exposure to chemicalsor toxins YES /NO @ OPlease specify.

Amalgam fillings @ NO ��

Frequent Antibiotic Use YES@ YES@

Previous lonq-termmedications (including contraceptive pill)J:iJCt3Je-I 0�� ���� ��

SCREENING/PATHOLOGY HISTORY

Screening Test / Pathology Date Result

Mammogram/ Breast Ultrasound &Q>f aCOT C'ns:T" - � ���� S IDePap Smear

�� ���� o K.. - c.M::/>,{LBone Density ---- ---Cholesterol � ;).ooq -:; -0PSA (Prostate Blood Test) .> .>¥-U:;iJ\:;": r I

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YourHealtli®NUTRITIONAL SUPPLEMENTS (vitamins, minerals etc.), HERBAL MEDICINES, HOMOEOPATHIC REMEDIES

Name Dosage

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CURRENT MEDICATIONS (prescription and non-prescription)

Name Dosage

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ALLERGIES JSENSITIVITIES (including medications, foods, dust mites, grasses, chemicals)

Allergies Jsensitivities Treatment

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SOCIAL HISTORY

Occupation ������0 JJc(LMarital Status MH <Ll'eoCigarettes JTobacco (strength &amount/day) iJO .

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YourHealttlAlcohol (type &amount/day) 00Recreational Drugs IJoExercise (type, duration &frequency) I.JORelaxation Techniques (e.g. meditation, yoga, tai chi) JJoDIET

Do you follow aspecific type ofdiet? Please circle. C§NO

Ifyes, please specify. (eg. Low fat, low carbohydrate, blood group, vegetarian etc.)

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What did you eat yesterday? Please complete the table below.

Breakfast MJ?teLunch ��� �������

�� �, /Dinner .

Snacks N .'

Sugar (tsp/day) / Tea (cups/day) I J/1> A , Coffee (cups/day) / Soft Drinks(per day)/ 1/"\VV ::J

Water (glasses/day) � ��� ��v

Other Drinks /Was this a typical day? Please circle. @ I NO

Please list the foods that you CRAVE. Please list the foods that you AVOID.

IMMUNISATIONHISTORYPlease record any immunisations you have received.TYPE DATE TYPE DATE

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YourHealttlCURRENT SYMPTOMSPlease tick thebox to therightofanycondition you are CURRENTLYEXPERIENCING.

GENERAL WEIGHT NERVOUS EYES EARS/ SYSTEM

Fatigue J Weight gain Headaches V Waterylitchy Itchy

Apathynethargy 1/ Difficulty losing vi Migraines Paintullred Ear achesweiohtHyperactivity Fluidretention vi Faintness V Stickyeyelids Infections

Poor appetite J Binge eating Oizziness V Blurred vision ./ Discharge

Hypoglycaemia Compulsive eating Numbness V Deteriorating V Tinnitus (ringing) V ,-vision

PocrV

'Craving forcertain V Tingling. pins& V Dry eyes Hearing losssleeolinsomnia foods neeelesSleepapnoea Weight loss Iv Poorco-ordination -/Excessive thirst J Eatingdisorders Feelcold easily ?

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Stress 1/ Coldhands & feet VEasybruising V

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DIGESTNE HEART/CIRCULATION LUNGS GYNAECOLOGICAL GENITO·SYSTEM URINARY

/ N ' Shortness of PMT (pre-V FrequentIndigestion High blood pressure V J menstrualV breath svndrome) urination

Heartburn/reftux Lowblood pressure V Cough Breast pain J Passing largeamounts ofurine, , Burning /

Bloating V High cholesterol V Sputum Breast lumps V discomfortonurination

Feel full easily V Chest pain V Blood Breast implants Discharge lkBurping Palpitations/arrhythmia V Chest tightness J Regular periods Blood in urine lFlatulence J Swelling ofankles Iv Wheeze v' Irregularperiods V Urgent urinationAbdominal/stomach

\.I Poor circulation ./ No periods Kidney painpainsorcrampsNausea Calf pain withexercise V V Difficultypassing V

V Heavyperiods urine Iv

J . 'PassingurineVomiting Varicose veins Menstrual clots J frequently al

niohtDifficulty / Jswallowinq V Periodpain/cramps Incontinence

Diarrhoea Iv Painful intercourse Lossof libido

Vaginal t/ ErectileConstipation dysfunctionirritation/soreness . Iimpolence)Piles Vaginal discharge V(haemorrhoids)Mucus Thrush /Rectal bleeding Menopausal V /

Anal itching Hotftushes V 1/Sweats ..../Vaginal dryness

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HISTORY continued

YourHealtttNOSE MOUTH / THROAT SKIN HAIR/NAILS JOINTS /

MUSCLESCongested/blocked Mouth ulcers \/ Acne/pimples HAIR Pain IvPoor sense of /smell Cold sores Eczema/dermatitis Dry Hair Swelling IvSinus problems Cracks atcorner Psoriasis Increasedhair J Stiffness /'

ofmouth loss !'\

Hayfever/allergy 1/ Sore throat Rosacea Arthritis

Sneezing Hoarseness, loss Rashes� 1/ NAILS Neck problemsofvoice .;

Excessive mucus Gum Hives/urticaria Soft Back problemsdisease/bleedinoPost-nasal drip Feeling of lump in \/ Dry skin Break easily V Cramps / spasms V

/"throatLoss oftaste Poor healing White spots Muscletwitching

,.-sensation \../

Bad breath Excessive ./ Ridged Muscle tension L ./sweatinaBody odour Fungal infections Muscle weakness L-- ./'->Dandruff Gout l..-""

EMOTIONS MIND�

Anxiety ,/ Poormemory r'Depression J Poorconcentration 1....-/Mood swings V Confusion 1/Panic attacks / Poor

..eomorehensionAnger, irritability ./ 'Brain fog' 1/

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YourHealtt,:Please complete the chart below indicating only chronic orsignificant illnesses (eg. Cancer, diabetes,asthma, arthritis, heart disease and blood pressure) within the appropriate box on the family medicalhistory tree.

FAMILYHISTORYGRANDFATHER GRANDMOTHER GRANDFATHER

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FATHER MOTHER({H- �����

AUNT /UNCLE : UNCLEf- CEfL.1A.)IJ&5

AUNT / UNCLE I( AlJNy' / �����IOjJ

AUNT / UNCLE r ����������

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BROTHER/SISTER BROTHER/SISTER

BROTHER/SISTER .. I BROTHER/SISTER

AS ����� DAUGHTER����� IiJ(, ,���� f-0efitESSIOJ.J����� ��������� 'f\'\l1(,.vE'

- liJ " "C-- 1fr ' . ��������� IHM- >In ,..-..r: / ISON DAUGHTER

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YourHealttlMETABOLIC SCREENING QUESTIONNAIRE

Please rate each ofthe following symptoms based upon your health profile for the past 30 days.o=Neveroralmost never have lhesymptom.1=Occasionally have it ellect isnotsevere.2=Occasionally have it effect is severe.3=Frequently have it, effect isnot severe.4=Freqentlyhave it effect is severe.

DIGESTIVE TRACT 2> Nausea or vomiting Total<>6 Diarrheao Constipation-5 Bloated Feelingo Belching, orpassing gas� Heartburn J2JIntestinal! Stomach pain

EARS o Itchy Ears Total� Earaches, ear infections

:6o Drainage from ears.2.J Ring inears, hearing loss -

EMOTIONS .;±-. Mood swings Total� Anxiety, fear ornervousness

'4II Anger, irritability, oraggressiveness:h Depression

ENERGY! ACTIVIY .3... Fatigue, slugglishness Total.;0 Apathy, lethargy

I. -.a. Hyperactivity'1 If- Restlessness or

EYES Q Watery or itchy eyes Totala Swollen, reddened orsticky eyelids;2, Bags ordarkcircles under eyes 53-.- Blurred ortunnel vision

(does not include near or far sightedness) -

HEAD .s: Headaches Total� Faintnesst Dizziness /2Insomnia

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HEART o Irregular orskipped heartbeat Total}- Rapid orpounding heartbeat 10Chestoain -

JOINTS! MUSCLES ,§L Pain oraches in joints Totalo Arthritis.L: Stiffness or limitation ofmovement� Painoraches in muscles :;!:f.- Feeling ofweakness ortiredness

LUNGS L Chest congestion Total(L Asthma,bronchitis

1..3 Shortness ofbreath� Difficultv breathing

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