ONLINE HEALTH APPRAISAL FORMTo help us understand your current state of health, please complete the following form Name * First Name Last Name Email * Age * Occupation * List your major health concerns at present. * YOUR HEALTH HISTORY Please select all health conditions that apply to YOU. Allergies / Eczema Low Blood Pressure High Blood Pressure Hay Fever / Sinusitis Asthma Anxiety / Depression Thyroid Disease Cancer Epilepsy Bleeding Disorders Gall Bladder Disease Joint Pain / Arthritis Skin Conditions Overweight / Obesity Kidney / Urinary Problems Bowel Conditions eg. Constipation, Diarrhoea Menstural Issues eg. PMS, Endometriosis Jaundice / Hepatitis A, B or C Diabetes High Cholesterol Heart Disease Other YOUR FAMILY'S HEALTH HISTORY Please select all health conditions that apply to your FAMILY. Allergies / Eczema Low Blood Pressure High Blood Pressure Hay Fever / Sinusitis Asthma Anxiety / Depression Thyroid Disease Cancer Epilepsy Bleeding Disorders Gall Bladder Disease Join Pain / Arthritis Skin Conditions Overweight / Obesity Kidney / Urinary Problems Bowel Conditions eg. Constipation, diarrhoea Menstural Issues eg. PMS, Endometriosis Jaundice / Hepatitis A, B or C Diabetes High Cholesterol Heart Disease Other MEDICATIONS & SUPPLEMENTS List your current medications List any vitamin or herbal supplements you take. DIET & LIFESTYLE Breakfast Lunch Dinner Snacks Water (Litres) Coffee (Cups / Day) Soft Drinks (Cans / Day) Alcohol (Standard Drinks / Day) Cigarettes Other Drugs Immune Frequent colds / influenza Allergies / Hayfever Frequent infections Slow wound healing Thrush Upper Gastro Intestinal Reflux Excessive Burping Bad breath Feeling of fullness after eating Stomach pain / nausea Liver Pale, clay-coloured stools Unexplained itchy skin Nausea Fatty foods cause nausea or indigestion Dark coloured urine Yellowish discolouration to skin / eyes Cardiovascular Chest pains Shortness of breath Palpitations Swelling in lower legs Varicose veins Easy bruising Redness in face High blood pressure Lower Gastro Intestinal Bloating Abdominal cramps / spasms Loose, watery stools Hard dry stools Constipation Blood or mucus in stools Alternating constipation / diarrhoea Excess gas Narrow stools Anal itching Thyroid Thyroid Easy weight gain Sensitive to cold Sensitive to heat Puffy face, hands, feet Dry skin Brittle hair / hair falls out Hoarse voice Insomnia Hard to gain weight Tremor Musculo-Skeletal Aches & pains Joint stiffness Joint deformities Cramps & spasms Restless legs Weakness Numbness, tingling Adrenals Feeling stressed, tense, nervous Irritable & oversensitive Frequent sad feelings Difficulty concentrating Tire easily Hard to get going in the morning Wakes during the night Hard to fall asleep Uses coffee, sugar, cigarettes as pick-me-ups. Blood Sugar Control Light headed Mild headache Difficulty concentrating if no food Excessive urination Profuse sweatiness Ulcers Slow wound healing Craves sweets / chocolates Skin Acne Psoriasis Warts Eczema Dandruff Tinea Rashes Nail problems Hormones (Male only) Difficulty sustaining an erection Low libido Poor hair growth Difficulty starting urine flow Dripping after urination Hormones (Female only) Menopausal Regular periods Period pain Heavy bleeding Bleeding between periods Breast tenderness Ovarian cysts / breast lumps Endometriosis Fibroids Painful intercourse Low libido Difficulty conceiving Premenstrual bloating Premenstrual depression / irritability / anxiety Migraines / headaches Your information has been received, thank you!
