Initial Consultation Form

Initial Consultation Form

Information within this form will be held as strictly confidential
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email*
example@example.com
Date of Birth
Gender

FemaleMale
Current health care practitioners
Relationship Status
Occupation
Height (cm)
Weight (kg)
Emergency contact name & phone number
Current medications & supplements
Medical History
Family Medical History
Presenting Health Concern/ Current Treatment (Please elaborate)
Childhood Health/ Other Medical Issues
Allergies/ Sensitivities (Environmental, animal, chemical, food, or other)
Have you had any chemical/ toxic exposure?
Digestive System Review: Please tick if applicable

Mouth ulcersBleeding gumsBad breathTasteCracked lipsTeeth problemsExcessive hungerHeart burnIndigestionBurpingNauseaBloatingVomitingFlatulenceConstipationDiarrhoeaHaemorrhoidsCrampingBloatingPainOther
Cardiovascular System Review: Please tick if applicable

High blood pressureLow blood pressureChest painPalpitationsAnginaDysrhythmiaDizziness on standingPain on exerciseFaintingOedema in legsPoor circulationCold hands or feetFluid retentionSwollen anklesNumbness or tinglingVaricose or spider veinsHot flushesLeg crampsOther
Nervous/ Sensory System Review: Please tick if applicable

HeadachesMigrainesTensionVertigo/ dizzinessNeck painLight headedEar infectionsEar dischargeDeafnessEaracheTinnitus/ ringing in earsParalysisBlack outsLoss of sensationTremorsOther
Respiratory System Review: Please tick if applicable

SinusitisHayfeverColdsNose bleedsPost nasal dripNasal stuffinessAsthmaWheezingShortness of breathSputumCoughBronchitisPneumoniaEmphysemaPleurisy/ tuberculosisOther
Urinary System Review: Please tick if applicable

UTI's/ CystitisPain passing urineNocturiaStonesFrequent urinationUrgency to urinateBurning passing urineIncontinenceOther
Muscular/ Skeletal System Review: Please tick if applicable

Injuries (Specify in Other)PainStiffnessSciaticaBroken bonesArthritisCrampsOther
Immune System Review: Please tick if applicable

InfectionsLong healing timeSwollen glandsSwellingFrequent infectionsGlandular fever in past/ presentViruses (please specify in other date and type)Frequent colds/ fluOther
Endocrine System Review: Please tick if applicable

Thyroid (please specify in other)DiabetesExcessive thirst/ hungerPolyuria (constantly passing urine)HypoglycaemiaWeight gain/ lossCravingsFatigueOther
Integumentary/ skin System Review: Please tick if applicable

DryOilyAcnePsoriasisEczema/ dermatitisPimplesFungal infectionsCold soresAlopeciaHair greyingOther
Emotional/ Psychological Review: Please tick if applicable

Panic attacksAnxietyPhobiasDepressionMood changesOther
Female Reproductive System Review: Please tick if applicable

Irregular menstrual cycleHeavyBloatingPMSCrampingPainMenopausePoor libidoMiscarriagesDifficulty falling pregnantInfectionsThrush/ CandidaDrynessSTD'sWartsSorenessHerpesPCOSEndometriosisFibroidsDysmennhorreaOther
Female Reproductive System: Elaborate on above if required
Females: Are you pregnant, or is there a possibility you could be?

YesNo
Are you currently trying to conceive?

YesNo
Females: Are you currently on the oral contraceptive pill?

YesNo
Females: If YES, how long have you been taking the Oral Contraceptive Pill?
Females: Have you ever taken the Oral Contraceptive Pill? How long ago, and for how long?
Male Reproductive System Review: Please tick if applicable

ProstateInfectionsSTD'sPainful urinationLow libidoOther
Current number of children
Do you have sleep difficulties, if so please specify:
On a scale of 1 (low) to 10 (high), please rate your energy levels:
Do you follow a particular diet? (e.g. Vegetarian, vegan, paleo, or other)
Sample daily diet
Do you smoke cigarettes?

YesNoSocially
If YES, how many per week?
Do you drink alcohol, and quantity per week?
Please upload relevant medical reports or results

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Additional Information
I understand and give full permission for my information to be kept on file securely and with the strictest of confidentiality

Yes I give full permission
I agree that at times I will communicate with Inspired By Wellness via email. This means that my personal information, consultation forms, medical reports or test results may be communicated or sent via email.

Yes I give full permission
I understand that my appointment will be secured once a minimum deposit of 25% of the consultation fee has been made. I agree that this is non-refundable if less than 48 hrs notice is given for rescheduling or cancelling.

Yes I understand and give permission for this
Payment Options:
Option 1 Online Bookings: Appointment was made through the online booking system and payment made at time of booking. (If a package was booked please select option 2 below).

YesNo - Choose option 2 or 3 below.
OR
Option 2 Bank transfer: A minimum 25% deposit is required for all consultations, excluding packages. Packages are of great value and therefore require payment in full to secure. Please transfer to the details below either a 25% deposit for a consultation or full payment for a package.

Commonwealth Bank, Dianna Bedran Trading As Inspired By Wellness, BSB 062-190 ACC 10619524
OR
Option 3 PayPal: Select tick box below and you will be redirected to PayPal after submitting this form. This option is not available for packages.
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Pay minimum deposit: Initial Consultation$40.00AUD

Pay in full: Initial Consultation$160.00AUD

Total $0.00AUD
An email will be sent to you after submitting this form, it has a Welcome Letter attachment containing general clinic info.

Please check all your email inboxes to ensure you receive all emails from Inspired By Wellness, including confirmation booking emails from our booking system.
Thank you for completing this form. Your wellbeing is important to us. Your email will be automatically added to our mailing list for our occasional newsletter containing free recipes and wellness advice. You may unsubscribe at any time via the link provided within the newsletter.
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