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Happiness in Health

Offering a Difference in Holistic Health Care

HISTORY:

What is the main reason for coming today? Please include date of onset:.................................................

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What are your main symptoms, including severity?

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What treatments have been tried so far, and outline what effects they have had.

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PATIENT DETAILS:

Name:............................................................................................... DOB:........................................

Medicare Card Details:.........................................................................................................................

Parents Names:....................................................................................................................................

Childrens Names:.................................................................................................................................

Marital Status and Partner's Name:.........................................................................................................

Address:..............................................................................................................................................

Mobile:.................................................. Home: .................................... Work:....................................

Email:..................................................................................................................................................

Private Health Insurance:.......................................................................................................................

Number:..............................................................................................................................................

Occupation:........................................................................................................................................

Referred By:.........................................................................................................................................

T. 07 5520 7511 • F. 07 5520 7522 • [email protected] • www.happinessinhealth.com.auHappiness In Health • Suite 5 1 / 1 Nerang Street, Nerang, QLD Page 1 of 7

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Expiry

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CURRENT MEDICAL ISSUES: Please include date of diagnosis:...........................................................................................................................................................

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PAST SURGERIES: Please include dates and any complications:...........................................................................................................................................................

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CURRENT MEDICATIONS: Please include date commenced and any benefits or side effects you feel are related to the medication:...........................................................................................................................................................

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PAST MEDICATIONS: Please include any medications you have been on in the past which have had a benefit or a negative effect giving details:...........................................................................................................................................................

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CURRENT SUPPLEMENTS AND VITAMINS:...........................................................................................................................................................

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Happiness in Health



Happiness in Health


GP'S:Name:.................................................................................... Phone:..................................................

Address................................................................................................................................................

Last Visit:..............................................................................................................................................

Address................................................................................................................................................

Last Visit:..............................................................................................................................................

Address................................................................................................................................................

Last Visit:..............................................................................................................................................

Address................................................................................................................................................

Last Visit:..............................................................................................................................................

Address................................................................................................................................................

Last Visit:..............................................................................................................................................

CURRENT HEALTH PROVIDERS

SPECIALISTS:

Name:....................................................................................Phone:..................................................

NUTRITIONIST/DIETITIAN:

Name:....................................................................................Phone:..................................................

NATUROPATH/HOMEOPATH:

Name:....................................................................................Phone:..................................................

OTHER THERAPISTS:

Name:....................................................................................Phone:..................................................


Happiness in Health

Offering a Difference in Holistic Health Care CHILDHOOD HISTORY:

0-6 MONTHS- if you don't know that's OK.1. Your mum's pregnancy- was it normal, what sort of birth, born at term?..........................................

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2. Were you breastfed? If so, for how long?.....................................................................................

3. Were you a refluxy baby?............................................................................................................

4. Were you a colicky baby?...........................................................................................................

5. Were you hard to settle, a poor sleeper?......................................................................................

CHILDHOOD - include details of severity and years diagnosedAsthma: q Yes q No.................................................................................................Eczema: q Yes q No.................................................................................................Tonsillitis: q Yes q No.................................................................................................Ear Infections: q Yes q No.................................................................................................Chesty when sick: q Yes q No.................................................................................................Constantly snotty: q Yes q No.................................................................................................Sinus: q Yes q No.................................................................................................Pneumonia: q Yes q No.................................................................................................Constipation: q Yes q No.................................................................................................Diarrhoea: q Yes q No.................................................................................................Food Intolerances: q Yes q No.................................................................................................Seizures: q Yes q No.................................................................................................Glandular Fever: q Yes q No.................................................................................................Thrush: q Yes q No.................................................................................................Recurrent Treatment with antibiotics: q Yes q No.................................................................................................Behavioural Issues: q Yes q No.................................................................................................Mental Health Issues: q Yes q No.................................................................................................Eating Disorders: q Yes q No.................................................................................................Excelled academically: q Yes q No.................................................................................................Did poorly academically:q Yes q No.................................................................................................Dyslexia: q Yes q No.................................................................................................Excelled at sport: q Yes q No.................................................................................................Excelled at art or music: q Yes q No.................................................................................................Other: q Yes q No.................................................................................................

IMMUNISATIONS: Are you immunised and have you ever had any reactions?

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Happiness in Health

Offering a Difference in Holistic Health Care DIETARY HISTORY:

Outline any known food allergies.

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Outline any food sensitivities, and include your reaction to that food or preservative.

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Do you crave certain foods, if so what?

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Please list the food and beverages normally consumed for three typical days:

DAY 1 Breakfast:.............................................................................................................................................

Morning snack(s):..................................................................................................................................

Lunch:..................................................................................................................................................

Afternoon snack(s):................................................................................................................................

Dinner:.................................................................................................................................................

Other:..................................................................................................................................................

DAY 2 Breakfast:.............................................................................................................................................

Morning snack(s):..................................................................................................................................

Lunch:..................................................................................................................................................


Dinner:.................................................................................................................................................

Other:..................................................................................................................................................

DAY 3 Breakfast:.............................................................................................................................................

Morning snack(s):..................................................................................................................................

Lunch:..................................................................................................................................................


Dinner:.................................................................................................................................................

Other:..................................................................................................................................................


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Happiness in Health


FAMILY HISTORY:

List any allergies, major illnesses, genetic disorders, and mental health disorders for each of the following members of your family:

Mother:...............................................................................................................................................

Father:.................................................................................................................................................

Siblings:...............................................................................................................................................

Maternal Grandmother:........................................................................................................................

Maternal Grandfather:..........................................................................................................................

Paternal Grandmother:.........................................................................................................................

Paternal Grandfather:...........................................................................................................................

Children:.............................................................................................................................................

Other:.................................................................................................................................................

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SOCIAL HISTORY:

Who lives at home with you?.................................................................................................................

Any pets?............................................................................................................................................

Is it a happy home?..............................................................................................................................

Any stressors within the home environment?............................................................................................

Do you have a support network of friends or family?................................................................................

What hobbies do you have and how often do you do them?.....................................................................What exercise do you do and how often?...............................................................................................

Do you smoke? Have you ever? Date quit............................................................................................

Do you drink? How many and how often and what do you drink? ...........................................................


Happiness in Health


ENVIRONMENTAL HISTORY:

Is your house mouldy or dusty? ............................................................................................................

Do you live near farming areas? ..........................................................................................................

Is your house or car new or near new? .................................................................................................

Do you live near power lines or industrial areas? ...................................................................................

What sort of water do you drink? ..........................................................................................................

Have you been exposed to chemicals through your home or work? If so, what? ........................................

Are you sensitive to any chemicals? .......................................................................................................

What sort of bedding do you have?.......................................................................................................

What sort of flooring do you have?.......................................................................................................

GENERAL HEALTH QUESTIONAIRE:

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Please read each statement and circle a number 0, 1, 2, or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.The rating scale is as follows:

0: Did not apply to me at all - NEVER1: Applied to me to some degree, or some of the time - SOMETIMES2: Applied to me to a considerable degree, or a good part of time - OFTEN3: Applied to me very much, or most of the time - ALMOST ALWAYS

I found it hard to wind down 0

I was aware of dryness of my mouth

I couldn’t seem to experience any positive feelings at all

I experienced breathing difficulty (eg. excessively rapid breathing, breathlessness in the absence of physical exertion)

I found it difficult to work up the initiative to do things

I tended to over-react to situations

I experienced trembling (eg. in the hands)

I felt that I was using a lot of nervous energy

I was worried about situations in which I might panic and make a fool of myself

I felt that I had nothing to look forward to

I found myself getting agitated

I found it difficult to relax

I felt down hearted and blue

I was intolerant of anything that kept me from getting on with what I was doing

I felt I was close to panic

I was unable to become enthusiastic about anything

I felt I wasn’t worth much as a person

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I felt that life was meaningless

I felt scared without any good reason

I was aware of the action of my heart in the absence of physical exertion (eg. sense of heart rate increase, heart missing a beat)

I felt that I was rather touchy

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FOR OFFICE USE

TOTALS

MENTAL HEALTH QUESTIONAIRE:Please complete this even if you are not presenting with a mental health issue.

Informed Consent for Treatment

Please read the following carefully and write down any questions you may have, we will be happy to

elaborate on them for you.

I will have the opportunity to discuss with the practitioner, the nature and purpose of treatment

with regards to my understanding of my signs and symptoms.

I understand, and am informed, that in the practice of medicine and holistic protocols, there are

potential risks to treatment.

I wish to rely on the practitioners to exercise their professional judgement during treatment,

regarding to my best interests at the time, based upon the facts known.

I have been encouraged to do some of my own research on the common protocols used in this

practice and have been given some useful links to get started in my welcome pack.

I understand that I can withdraw my consent at any time.

I _________________________ understand that the time I book with my practitioner is specifically reserved

for me. Therefore, I must give 24 hours’ notice to change/cancel appointments; otherwise a cancellation fee

will be applied. This enables us to offer your appointment to other patients who require treatment. You will

receive a courtesy SMS reminder 1 week prior to your appointment and a courtesy reminder call 1 day prior

to your appointments.

[ ] I wish to receive the clinic newsletter via email.

I ___________________________ understand and agree to all the terms above. Date: _________________

I hereby consent to having holistic/naturopathic treatment on me or my children by my nominated

practitioner under the employ of Happiness In Health.

I have read the above, and I have also had the opportunity to ask questions about its content. I

intend this consent to cover the entire course of treatment for mine or my families present

condition, and for other future condition(s) for which we seek treatment.

T. 07 5520 7511 • F. 07 5520 7522 • [email protected] • www.happinessinhealth.com.auHappiness In Health • Suite 5 1 / 1 Nerang Street, Nerang, QLD

[email protected]

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[email protected]

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Happiness in Healthhappinessinhealth.com.au/wp-content/uploads/patient_forms/Happin… · Happiness In Health • Suite 5 1 / 1 Nerang Street, Nerang, QLD. Page 7 of 7. Please read