Acquaintance SheetDate: ______________________________________________

Surname: _________________________________________ Given name: _________________________________________________

Address: __________________________________________________________________________________________________________

Suburb: ___________________________________________ Postcode: ____________________________________________________

Home Phone: ______________________________________ Work Phone: _________________________________________________

Mobile Phone: _____________________________________ Email: ________________________________________________________

My present weight: _____________________________kg

My goal weight: _________________________________kg

Sex: _______________________________________________ Occupation: _________________________________________________

Age: _______________________________________________ Marital Status: _______________________________________________

Date of Birth: ______________________________________

You will be sent an appointment reminder via text. If you do not wish to receive an appointment reminder please tick here.

Please tick how you have found us or if you were referred by someone (Please include their name)

Physician (Name: ______________________) Google search (Key word: ________________)

Physiotherapist (Name: _________________) Google Ad

Friend or Family (Name: _________________) Loconut.com.au

Flyer (From where? ____________________) One Stop Health

Flyer from Friend at BBN (Name: ___________)

Natural Therapy Pages

Living Social Craig Smith – In Body

White Pages Sign/Driving by

Little Aussie Directory Embody Health – massage

Yellow pages online Other (Name: ________________________)

Medical History QuestionnaireDate: _______________________________________ Name:___________________________________________

Please tick any of the conditions or symptoms you currently suffer or have a history of:PAIN/INFLAMMATION: Headaches

Migraines

Arthritis

Gout

Back

Neck

Other:________________________

ALLERGIES: Foods:________________________

Hay Fever

Psoriasis

Eczema

Asthma

THYROID: Hypo

Hyper

OTHER: _______________________________

_______________________________

_______________________________

BLOOD SUGAR/CRAVINGS: Diabetes

Hypoglycemia

Crave sugar/starch (circle)

Crave salt

Crave caffeine

ADRENALS: Energy = _____/10

Wake up tired

Tired all day

Slump in energy @ ______ (time)

2nd wind in evening

BED TIME: ________

Hard to fall asleep. Duration: ______

Wake often. # times: ______ Hard to refall. Duration awake: ______

Groggy when wake in morning

GASTROINTESTINAL: Bowels/day: ____

Constipation/Bowels/wk: ____

Not completely evacuated

Gas

Cramps

Bloating

Irritable Bowl Syndrome

Diverticulitis

HEART/CIRCULATORY: High Blood Pressure

High Cholesterol

Dizziness

Anemia

MOOD: Irritable

Depressed/Flat (circle)

Anxiety

Medical History Questionnaire cont.REPRODUCTIVE FEMALE:PMS symptoms

Fatigue

Irritable/Teary/Depressed (circle)

Bloated/Water retention (circle)

Hunger/crave sugar or starch (circle)

Breast tenderness/swelling (circle)

Headaches

Loose bowel/constipated (circle)

Menstruation

Regular/Irregular cycle (circle)

Duration of flow: _____ days

Brown blood: starting/trailing

Heavy/clots (circle)

Cramps/pain

Conditions

Endometriosis

Polycystic Ovaries

Fibroids

Menopause

Hot flushes/sweats

Irritable/Depressed/Anxiety (circle)

Crave sugar/starch/caffeine

Low libido

Headaches

Insomnia

OTHER HISTORY:SMOKING

Do you smoke? Y/N (circle)

If you used to smoke, when did you quit? (date) _________________________________

COFFEE

Cups of coffee per day?________________

Cups of tea per day?___________________ALCOHOL

Daily?_________________________________

Weekends? ____________________________

Rarely? _______________________________ARE YOU TAKING ANY OTHER MEDICATIONS? Blood Pressure

Cholesterol

Cardiac Medication/Beta Blockers

Diuretics

ANTI Depressants/Anxiety

Tranquilizers

Hormones/HRT

Birth Control Pills

Aspirin

Vitamins/Herbs

Laxatives

Over the counter prescriptions

Steroids (eg. Prednisone, Cortisol, Cortisone)

Arthritic

Anti-inflammatories

Pre-visit CriteriaDear Patient,

Please follow the below criteria before coming in for your body fat analysis.

By adhering to these guidelines we can get an accurate assessment of your body composition. This information will help us fine-tune your program, and track your results.

A body composition analysis will be completed at the Initial Consultation and every Progress Evaluation thereafter. Progress Evaluations are generally every second consultation.

1. Alcoholic beverages should NOT be consumed for at least 12 hours prior to the test.2. Do not exercise strenuously 12 hours or less before the test.3. Do not excessively eat or drink water the day before the test.4. Do not eat or drink for a period of 3 hours prior to the test (you may sip water when needed).5. Urinate immediately before the test.6. Please advise if you are pre-menstrual or are menstruating.

THANK YOU!A

WHERE?

176a Cambridge St, West Leederville. We are next to the NE corner of Connolly Street and Cambridge Street, opposite the main driveway to St John of Gods Hospital.

PARKING?

You will find ticket parking on Connolly Street or we offer 2 Free car bays underneath the building.

From Connolly Street turn in to Stent Lane, see map above. Drive down the steep driveway between the two white walls. Our bays are located at the far end of the car park. Please do not park in any other bays except the ones marked BBN Customer parking.

EMAIL FORMS BACK

Please read, fill in and EMAIL these forms back to us by 5pm the day before your visit.

This will streamline your experience.

NOTE: Children are welcome at BBN. We have a crèche facility with a DVD player and toys, with a childproof gate.

CANCELLATION POLICY

Our Nutritionists time is valuable so please let us know 24 hours in advance if you need to reschedule or cancel. A $25 NO SHOW fee will apply if you do not turn up to your appointment without notice. We appreciate your cooperation as often we can re-book that appointment with people on the waiting list.