Health Questionnaire Please complete all 3 pages
Name: ………………………………………………………….
What is the main reason for attending our clinic?……………………
	Please tick the appropriate column
Topic	Have you had……	never	In the past	Recently	frequently
Digestion	Heartburn or reflux
	Bloating after meals
	Constipation
	Burping, Farting or wind
	diarrhoea or loose stools
	Nausea (feeling like vomiting)
	Stomach ulcers or Stomach pain
	Gall bladder problems
Lung	Asthma or Emphysema
	Pneumonia or Bronchitis
	Wheeze after viral infection
	Wheeze after exercise
Immune system	Boils
	Cold sores
	Conjunctivitis
	Ear infection
	Genital infection
	Mouth ulcers
	Sinus infection
	Sore throat
	Thrush
	Tonsillitis
	Urinary infection
Skin, Hair & Nails	Acne or pimples
	Brittle nails
	Dry eyes or mouth
	Dry skin
	Eczema or Dermatitis
	Hair loss
	Psoriasis
	Rashes
	Sore or cracked lips
	Tinea or ringworm
	Warts
Do you have allergies?		No	Yes
Allergy	Medications			list ……………………
	Foods or herbs			list ……………………
	Hay fever or sinus trouble
	Nasal blockage
	Other			list ……………………
		never	In the past	Recently	frequently
Gynaecological	Abnormal PAP smears
	Breast Cyst or lumps
	Breast tenderness
	Endometriosis
	Fibroids
	Ovarian cysts
	PMS/PMT
	been on HRT
	been on oral contraceptive
		never	In the past	Recently	frequently
Urinary	Cystitis or Kidney infection
	Prolapse
	Stones
		No	Yes	Year
Any Liver problems?	Hepatitis or Jaundice
	Abnormal liver function tests
	Liver damage or Fatty liver
		never	In the past	Recently	frequently
Heart	Angina or Chest pain
	cold hands & feet
	Fluid retention
	Heart Attack
	Heart failure
	Heart murmur
	High blood pressure
	Palpitations or Irregular heart rate
		never	In the past	Recently	frequently
Sleep	disrupted sleep
	insomnia
	snoring
	unrefreshed sleep
	Have you had……	never	In the past	Recently	frequently
Nervous system	Agitation or Anxiety
Muscle system	Blurred vision
	Chronic pain
	Depression
	Dizziness or Vertigo
	Facial twitching
	fidgeting or Restless legs
	Fits or seizures
	Leg/foot or hand cramps
	loss of balance
	Memory loss
	Migraine or other headache
	Mood swings or Irritability
	Muscle pain
	Muscle weakness/heaviness
	Pins & needles / Numbness
	Poor concentration
	Tinnitus (ringing in the ears)
	Tremor of the hands
	Weakness of a limb
Have you ever had an accident?		No	Yes
Accident	Car
	Plane
	Motorcycle
	Marine
	Bicycle
	industrial
	work
	Sporting
Weight	Overweight
	anorexia bulimia
	weight loss
Have you ever suffered from…..		No	Yes
Blood disorders	Anaemia
	Low Platelet count
	Iron deficiency
	Easy bruising
	Low White cell count
Have you had blood clots?
Blood clot	Deep vein thrombosis
	Pulmonary embolus
Have you ever suffered from…..
	Osteo Arthritis
	Rheumatoid arthritis
	Gout
	Lupus
	Ankylosing spondylitis
	other
Have you had cancer?		No	Yes	Year
Cancer	Melanoma or other skin
	Breast
	Ovary or uterus
	Lung
	Lymphoma or leukaemia
	Stomach or Colon
	Other			list ……………………
		No	Yes	Year
Have you ever had	Candida
	Chronic fatigue/fibromyalgia
	Helicobacter infection
	Glandular fever
	Leaky Gut Syndrome
	Mycoplasma
	Oral or genital herpes
	Ross River Virus
	Shingles
Do you have any of these?		No	Yes
Hormone	Diabetes
	Thyroid problems
Do you take any prescription drugs? If so, please list them …………………………………….
Do you take any naturopathics  ? If so, please list them …………………………………….
Do you know your blood group? …………………….
Do you take any vitamin/ mineral supplements? If so, please list them …………………………………….
Have you had any operations? If so please list them ……………………………
Have you been on medication in the past? If so list them ……………………………………………………..
Do any foods upset you?……………………………………
Are there any diseases that run strongly in your family?……………………………..
Are you vegetarian?………………………………..
How many doctors have you seen about your problem so far? …………………………………….