Natural Wellness Albert Park
Health History Questionnaire
Name
*
First Name
Last Name
Email (please note email address is used only for communication and reconfirmation of appointments).
*
example@example.com
Please tick if you would like to receive our newsletter and information on upcoming events at Natural Wellness Albert Park.
Yes
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Date of birth
*
/
Day
/
Month
Year
Date
Gender
*
Female
Male
Transgender
Emergency Contact
Name
Phone Number
Doctor's Details
Name
Email/Phone
Occupation (we ask this because it may be relevant to your health issue)
Main issues you would like to address in order of importance to you.
Have you been given a diagnosis for the problem? If so what?
What kinds of treatment have you tried for this problem?
Please state whether you are currently suffering or have in the past suffered from any chronic or pre-existing illnesses, such as:
Arthritis
Epilepsy
Asthma
Diabetes
Infectious diseases (HIV, Hepatitis)
Heart disorder
Bleeding disorders
Depression
Cancer
Are you currently taking any medications/supplements (prescribed AND non-prescribed) including drugs, herbs, vitamins etc.? Please list:
Any allergies? Please list:
How did you find Natural Wellness Albert Park?
Internet / Website
Social Media
Friend or Family (please provide name below, so we can thank them)
Health Practitioner (please provide details below)
Local / Walked past
Other (please specify)
Other
Name of person who referred you to Natural Wellness Albert Park
First Name
Last Name
Signature
*
Date
/
Day
/
Month
Year
Date
Submit
Should be Empty: