pure element healthcare
PH: 0401 318 593 date today
Name:
Date of birth:
Address:
Home phone:
Mobile:
Email:
Referred by:
Occupation:
Health Fund:
Blood type (if known):
Other health professionals you visit:
If you are pregnant, how many weeks are you? ____
Have you ever miscarried? _______
Children (name, age, gender):
Spouse/ Partner name:
Past trauma/ accidents (inc. date, age):
Past surgery (inc. date, age)
Childhood and other illnesses (inc. date, age):
Current supplements or medication:
Food preferences (circle): meat + 3 veg
Daily Intake:
coffee:
tea:
vegan
vegetarian
high protein
gluten free
dairy free
other:
alcohol:
smoking:
water:
wheat free
Exercise:
Reasons why you are here (circle): stress / relaxation / maintenance / other details below:
Is there anything else I should know?
On a scale of 1 – 10 (10 being most), how committed are you to your wellbeing? ________
How did you find out about me?
I am aware the Cancellation Policy of this clinic is: “If we need to cancel your appointment, we will give you 24 hours notice plus treat
you for free on your next visit. If you need to cancel your appointment with less than 24 hours notice, or fail to show for a scheduled
appointment, you will incur a 100% cancellation fee, as someone else could have come in your place.”
Signed____________________ Date __________
CONDITION
Back:
Lower
Middle
Upper
Neck
Jaw
Arms:
Shoulders
Elbows
Wrists
Hands
Fingers
Legs:
Hips
Knees
Ankles
Feet
Toes
Alcoholism/Addictions
Allergies
Anxiety
Arthritis
Asthma
Blood Pressure High /
Low
Chronic Pain
Circulation
Cramps/Spasms
Cystitis
Depression
Diarrhea / Constipation
Digestive disorders
Earache
Eyestrain
Heartburn
Headaches/migraines
Indigestion
Insomnia
Menopause
PMT
Sciatica
Sinus
Tinnitus
Weak Bladder
Stress today :low/ med/
high
Other
please tick
DETAILS