First Name
*
Last Name
*
Date
*
1. What are your top 3 health issues that prompted you to make an appointment with our practice?
*
2. How do you rate your general health?
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Very FIt
Good
Not Very Healthy
3. Are there any medical conditions for which you take regular medications?
4. Have you had any previous surgery (specifically on the abdomen)?
5. Do you Smoke?
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Yes
No
6. Do you Drink?
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Yes
No
7. Do you get a healthy amount and quality of Sleep?
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Yes
No
8. Do you engage in regular exercise (at least 3-4 times a week)?
*
Yes
No
9. How would you rate your diet? Are most of the meals:
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Healthy
Moderately Healthy
Mostly fast/junk food
10. What Dietary type are you?
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Regular Meat Eater
Vegetarian (No Meat or Fish)
Vegan
11. When do you generally have dinner?
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5-7 pm
7-9 pm
After 9 pm
12. Do you have an allergy, problems with frequent colds?
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Yes
No
13. Do you experience difficulty focusing -Brain fog?
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Yes
No
14. How do you handle emotional challenges and stress?
*
15. Do you experience poor self image or self esteem leading to depression or anxiety?
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Yes
No
16. Do you take time for self care and relaxation?
*
Yes
No
If yes, how much per week?
17. Do you maintain a healthy weight? If not what, in your view is the main reason for this?
*
18. Do you have any health goals that you want to achieve in the next 12 months? Please List:
*
GASTROINTESTINAL QUESTIONNAIRE
Do you experience any of the following symptoms
1. Indigestion
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Yes
No
Severe
2. Excess belching, burping
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Yes
No
Severe
3. Bloating or fullness commencing, during, or shortly after a meal
*
Yes
No
Severe
4. Sensation of food sitting in stomach for a prolonged period after a meal
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Yes
No
Severe
5. Bad breath
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Yes
No
6. History of anaemia or blood loss
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Yes
No
7. Indigestion or heartburn with spicy or fatty food, citrus, alcohol, or caffeine
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Yes
No
8. Heartburn aggravated by lying down or bending forward, to waking up from a sleep at night with a choking sensation?
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Yes
No
9. Difficulty or pain when swallowing?
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Yes
No
10. Vomiting blood or vomitus that has an appearance of coffee grounds
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Yes
No
11. Abdominal pain, cramping and/or spasms
*
Yes
No
12. Diarrhoea (loose, watery or frequent bowel movements
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Yes
No
13. Constipation (requiring straining, or a hard, dry or small stool)
*
Yes
No
14. Alternating diarrhoea and constipation
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Yes
No
15. Sensation of incomplete emptying of bowel
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Yes
No
16. Red blood with bowel movement or black tarry stools
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Yes
No
17. Rectal pain or cramps
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Yes
No
18. Anal itching
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Yes
No
19. Fatty foods cause indigestion or nausea
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Yes
No
20. Yellowish discolouration of skin or eyes
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Yes
No
21. Skin rashes, acne, dermatitis, or eczema
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Yes
No
22. Difficulty gaining or losing weight
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Yes
No
23. Do you have a confirmed diagnosis of sleep apnoea?
*
Yes
No
24. Do you snore loudly?
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Yes
No
25. Do you often feel tired/fatigued during the daytime?
*
Yes
No
26. Has anyone observed you stop breathing during your sleep?
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Yes
No
27. Do you have or are you being treated for high blood sugar/diabetes/heart attack/angina?
*
Yes
No
28. Do you have a history of blood clot/deep vein thrombosis/pulmonary embolism?
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Yes
No
29.Are you able to climb more than l flight of stairs without stopping?
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Yes
No
Submit