First Time Evaluation Form

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The information provided in this form is strictly confidential.

Please complete this form carefully. The information provided will help us build a personalised healthcare programme for you.

Please do not take any supplements for 2 meals prior to your first evaluation.

(fields marked with * are required)

Biographical Details
First Name*
E-mail*

Mailing Address*

Blood Type*
Weight (Kg)
Height (cm)
Date of Birth*
Age (Years)
Gender

Current Occupation*
Marital Status*
Referring Practitioner
Chief Concerns
Please list your current health concerns and rate their severity (on a scale of 1 – 10, 10 being most severe)

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Health History
Please provide a detailed timeline of your personal health history, from childhood. Include all major traumas (physical and emotional), operations and illnesses, the age you were and what changes you experienced in your health.

2500 characters remaining
Other Therapies
If you have tried therapies to help these issues in the past, what was successful and what was not?

1000 characters remaining
Medications
Please list any medications you are currently taking, including self-prescribed medications such as Panadol etc.

Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Supplements
Please list supplements that you currently take and include brand names.

Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Health Overview
Energy

Please rate your current energy level (on a scale of 1-10, 10 being the highest energy)

1


Does your energy change through the day and if so how does the scale change:

Other:
Sleep

How is your sleep?

RestfulRestlessHard to get to sleepWake oftenGet up during nightBad dreams

Other
What time do you usually sleep?
How many hours per night?
Exercise
What kind of exercise do you do?
How often do you exercise?
For how long at a time?
Stress

Please rate your current stress level (scale of 1-10, 10 being highest)

1
What is the main reason for your stress?
What steps are you taking to reduce your stress level?
Emotional
Please list any psychological or emotional issues that you are currently experiencing.
How would you describe your overall mood?
Eyes & Ears

Do you wear glassesContact lensesHad laser eye surgeryCataractsGlaucomaPoor night visionWear hearing aidsHave impaired hearingPoor night visionTinnitus

Other
Sunlight
Hours of natural sunlight you receive daily outside?
Hours of sunlight you receive daily through windows?
Hours spent daily under fluorescent lights?
Urination

How are your daily urinations?
2-3 hoursToo frequentSense of urgencyToo small amountToo large amountBurningDribblingUp several times at night

Other
Digestion

How is your digestion?
AdequatePoorAcid refluxBurp oftenGasBloatingBurning / pain in stomachPain before bowel movementNausea before bowel movement

Other
Bowels

Eliminations per day

Other
Amount
NormalToo littleToo large
Consistency
Easy to passDifficult to passFormedToo hardFalls apart in toiletFloatsSoftLoose

Additional info

Women's Health
Are you pregnant or breastfeeding?
YesNo
Are your periods regular?
YesNo
Have you had a hysterectomy?
YesNo
Are you going through menopause?
YesNo
Had an episiotomy or a C-section?
YesNo
Had an epidural?
YesNo
Have you struggled with fertility/miscarriage?
YesNo
Do you have a history of low Iron levels?
YesNo
Are you experiencing any of the following?

Hot flashesNight SweatsDrop in libidoPainful periodsCramping
Men's Health
Have you experienced a drop in muscular strength, drive or libido?
YesNo

If you answered yes, please explain further:

Pets
Do you have any pets?
YesNo
Is it allowed in all areas of the house?
YesNo

What do you feed your pet(s)?

Do you frequently de-worm your pets?
YesNo
Chemical Exposure
Personal Care & Household Products (please indicate products & brands)

Perfume/Cologne
Hair Product
Shampoo
Cleanser
Hand/Body Lotion
Toothpaste
Make-up
Hair Dye
Nail Polish Remover
Deodorant
Moisturiser
Soap
Shave Cream
Conditioner
Nail Polish

Other chemical exposure from personal care products

Dishwashing
Air Freshener
Fly Spray
Paint
Laundry Soap
Glass Cleaner
Pesticides
All-Purpose
Insecticides
Fertilisers
Toilet Cleaner
Herbicides
Bleach

Other chemical exposure (from garden, work, art chemicals, etc)

Electromagnetic Exposure
How many hours per day do you spend...

Watching TV
0
Computer use
0
On landline phone
0
On mobile phone
0
Wearing a pager
0
Wearing a headset
0
Wearing a watch
0
Wearing hearing aids
0
Travelling by vehicle
0
Body Systems
Tick the individual symptoms being experienced and indicate 1 to 5 degree of severity. 5 being very severe.

LY I experience recurrent infections, sinusitis, post nasal drip or swollen lymph nodes... 0
LU I experience recurrent respiratory infections, coughs, bronchitis, pneumonia, asthma... 0
LI I experience bouts of diarrhoea, constipation, gas, bloating... 0
NE I experience irritability, nervousness, trembling, anxiety, memory problems... 0
CI I have cold fingers/toes, blood pressure problems, varicose veins, circulation issues... 0
AL I react to pollens, moulds, foods, seasonal irritants, perfumes, animal dander... 0
TH I have a slow metabolism, am always hungry, have low energy at specific times of day... 0
TW I have mood swings, problems sleeping, am always cold, have chemical imbalances... 0
HT I experience heart palpitations, pain in my chest, irregular heart beat... 0
SI I have recurrent yeast infections, frequent antibiotic use, poor diet... 0
JT I experience joint pain, stiffness, inflammation in my body... 0
PA I have diabetes, blood sugar issues, irritability, shaking if I skip a meal... 0
SP I experience chronic fatigue, recurring infections, get sick easily... 0
LV I experience high cholesterol, wake up between 2-4am, indigestion after fatty meals... 0
SK I have rashes, dryness or cracking, scaly patches, eczema, acne, psoriasis... 0
GD I struggle with impotence, libido, miscarriages, sterility... 0
UB I have recurring urinary tract infections, painful urination, leaking, urinary frequency... 0
KI I experience swelling, gout, pain in the lower back, history of kidney stones... 0
Surgeries / Injuries
What surgeries, operations, traumas, car accidents, etc have you had?

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Have you ever had full body anaesthesia (ie. To remove tonsils, wisdom teeth, etc)?
YesNo
Have you had elective surgery (rhinoplasty, tummy tuck, liposuction, mole removal, etc)?
YesNo
Do you have any tattoos?
YesNo
Scars
Please describe any scars on your body (major and minor ones)

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Personal Health Goals
How important is your health to you on a scale of 1-10 (10 being highest)?

1
How much confidence do you have in your body’s ability to heal itself given the right nutrients & natural therapies? On a scale of 1-10 (10 being high)?

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How much confidence do you have in medical drugs, on a scale of 1-10 (10 being high)?

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What is most important to you in a health practitioner team?
What are your specific health goals? (What do you really want?)
How much money do you spend per month on your health?
How far are you willing to commit to achieve your health goals? (Please be honest)

Don’t really want to change muchWilling to change a reasonable amount
How long do you want to live? (Check all that apply)

Age 60-70Age 70-80Age 80-90Age 90-100Age 100+
only if my significant other is still alive alsoas long as I have been granteduntil I complete my mission (purpose) on earth
as long as I’m healthyit’s already enoughforever
Doshas – Vata / Pitta / Kapha

Energy Imbalances - Please tick the symptoms which you are experiencing regularly...

VATA
Please indicate total number of checks

WorriedWeaknessIndecisiveNail bitingShy, insecureHeart palpitationsDry, rough, flaky skinHeadaches
Fainting spells, dizzinessFatigue, poor staminaGeneralised aches, painsVery sensitive to coldDry, sore throat, dry eyesTired, yet can’t relaxAnxious, fearful, nervous
Low back pain or menstrual crampingAgitated mind, difficulty concentratingConstipation, intestinal gas, bloatingAntsy or hyperactive behaviourArthritis, stiff & painful jointsLosing weight, underweightInsomnia, wake up at night

PITTA
Please indicate total number of checks

BoilsImpatientSkin rashesAngry, irritableInflammationFlushed faceBlood-shot eyesAcne, rosacea
Argumentative, bossyFevers, night sweatsSour body odourFrustrated, wilfulHostile, destructiveBossy, controllingDiarrhoea, loose stools
Very sensitive to heat, hot flashesWeakness due to low blood sugarBad breath, bitter taste in mouthExcessive hunger or thirstDisturbing, violent dreamsCritical of self and othersAcidity, heartburn, ulcer

KAPHA
Please indicate total number of checks

NauseaDiabetesSlow to reactGroggy all dayHigh cholesterolAllergies, hayfeverApathetic, no ambitionSleeping too much
Slow to comprehendPale, cool, clammy skinProcrastinating, lethargySluggish dull thinkingWeight gain, obesityWater retention, swellingDepressed, sad, overly sensitive
Mucus & congestion in sinuses/noseGreedy, possessive, materialisticClingy, hanging onto people/ideasBody & limbs feel heavy, swollenVery tired in morning, hard to get upMucus & congestion in throat/chestSluggish digestion, mucus in stools

Dental Health

When was your last dental appointment and what treatments were done?

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Do you have any dental concerns?

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Do you currently have or have you ever had any amalgam/silver fillings?
YesNo
Do you experience any of the following?

Receding gumsTooth painMouth ulcers

Other symptoms?

Toxic Burden
Smoking
Do you currently smoke?
If yes, how much?
How long have you smoked?

Do you frequently breathe second-hand smoke from others who are smoking (either at home or work)?

Alcohol
Do you drink alcohol?

DailyWeekly

What do you drink and how much?

Recreational Drugs - This is strictly confidential information

Do you currently use recreational drugs?

MarijuanaHeroin
EcstasyUppers
CocaineDowners

Methamphetamine
Others?

Have you used recreational drugs in the past?
BACTERIA
Yellow/green dischargeSymptoms persist longer than 10-14 days

I am concerned about this group...

VIRUSES
Clear dischargeBody-wide aches/fatigue

I am concerned about this group...

MOULD / FUNGUS
Frequent antibiotic useWhite, coated tongue

I am concerned about this group...

HEAVY METALS
Exposure through vaccinations/jobMemory difficulties

I am concerned about this group...

CHEMICALS
Use commercial cleaning productsMemory difficulties

I am concerned about this group...

PESTICIDES
Eat non-organic produce and animal productsDrink/bathe in unfiltered tap water

I am concerned about this group...

PARASITES
History of digestive upsetItching skin, especially at night

I am concerned about this group...

Detoxification
Previous Cleansing Experience - Please check the organs which you have cleansed in this past year.

ColonLiver/Gallbladder

What benefits or difficulties did you experience?

Are you ready to detox?
Detoxification requires energy of the body. Please check the following criteria that applies:
I am not pregnant or breastfeedingI am having a daily bowel movementI am willing to stay hydrated (daily quantity of good quality water: weight x 0.03 = litres of water)I can handle temporary reduction in energy or short-term flare in my symptoms during detoxificationI am willing to measure my 1st morning urinary pH to make sure that my pH is between 6.4 and 7.2

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