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
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

Other
Cardiovascular System Review: Please tick if applicable

Other
Nervous/ Sensory System Review: Please tick if applicable

Other
Respiratory System Review: Please tick if applicable

Other
Urinary System Review: Please tick if applicable

Other
Muscular/ Skeletal System Review: Please tick if applicable

Other
Immune System Review: Please tick if applicable

Other
Endocrine System Review: Please tick if applicable

Other
Integumentary/ skin System Review: Please tick if applicable

Other
Emotional/ Psychological Review: Please tick if applicable

Other
Female Reproductive System Review: Please tick if applicable

Other
Female Reproductive System: Elaborate on above if required
Females: Are you pregnant, or is there a possibility you could be?
Are you currently trying to conceive?
Females: Are you currently on the oral contraceptive pill?
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

Other
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?
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
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.
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.
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).
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.
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$40.00 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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Initial Consultation Form

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.