Initial Consultation Form

Initial Consultation Form

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

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

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

Female Male
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 ulcers Bleeding gums Bad breath Taste Cracked lips Teeth problems Excessive hunger Heart burn Indigestion Burping Nausea Bloating Vomiting Flatulence Constipation Diarrhoea Haemorrhoids Cramping Bloating Pain
Cardiovascular System Review: Please tick if applicable

High blood pressure Low blood pressure Chest pain Palpitations Angina Dysrhythmia Dizziness on standing Pain on exercise Fainting Oedema in legs Poor circulation Cold hands or feet Fluid retention Swollen ankles Numbness or tingling Varicose or spider veins Hot flushes Leg cramps
Nervous/ Sensory System Review: Please tick if applicable

Headaches Migraines Tension Vertigo/ dizziness Neck pain Light headed Ear infections Ear discharge Deafness Earache Tinnitus/ ringing in ears Paralysis Black outs Loss of sensation Tremors
Respiratory System Review: Please tick if applicable

Sinusitis Hayfever Colds Nose bleeds Post nasal drip Nasal stuffiness Asthma Wheezing Shortness of breath Sputum Cough Bronchitis Pneumonia Emphysema Pleurisy/ tuberculosis
Urinary System Review: Please tick if applicable

UTI's/ Cystitis Pain passing urine Nocturia Stones Frequent urination Urgency to urinate Burning passing urine Incontinence
Muscular/ Skeletal System Review: Please tick if applicable

Injuries (Specify in Other) Pain Stiffness Sciatica Broken bones Arthritis Cramps
Immune System Review: Please tick if applicable

Infections Long healing time Swollen glands Swelling Frequent infections Glandular fever in past/ present Viruses (please specify in other date and type) Frequent colds/ flu
Endocrine System Review: Please tick if applicable

Thyroid (please specify in other) Diabetes Excessive thirst/ hunger Polyuria (constantly passing urine) Hypoglycaemia Weight gain/ loss Cravings Fatigue
Integumentary/ skin System Review: Please tick if applicable

Dry Oily Acne Psoriasis Eczema/ dermatitis Pimples Fungal infections Cold sores Alopecia Hair greying
Emotional/ Psychological Review: Please tick if applicable

Panic attacks Anxiety Phobias Depression Mood changes
Female Reproductive System Review: Please tick if applicable

Irregular menstrual cycle Heavy Bloating PMS Cramping Pain Menopause Poor libido Miscarriages Difficulty falling pregnant Infections Thrush/ Candida Dryness STD's Warts Soreness Herpes PCOS Endometriosis Fibroids Dysmennhorrea
Female Reproductive System: Elaborate on above if required
Females: Are you pregnant, or is there a possibility you could be?

Yes No
Are you currently trying to conceive?

Yes No
Females: Are you currently on the oral contraceptive pill?

Yes No
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

Prostate Infections STD's Painful urination Low libido
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?

Yes No Socially
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).

Yes No - 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.

Pay minimum deposit: Initial Consultation $ 40.00 AUD

Pay in full: Initial Consultation $ 160.00 AUD

Total $ 0.00 AUD
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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