Download Michael Beilby`s New Patient Questionnaire

General Consent Form and Authority
to Release and Obtain Information
YourHealth Manly Pty Ltd
15 South Steyne, Manly NSW 2095, Australia
Ph: 02 9977 7888 Fax: 02 9977 3436
www.yourhealth.com.au
CONFIDENTIAL PATIENT QUESTIONNAIRE
Please complete the following questionnaire. Your response remains confidential and will provide
information for your practitioner to use in your assessment and treatment.
Surname:
Title:
First Name:
Date of Birth:
Gender:
FEMALE / MALE
Marital Status:
Mr / Mrs / Ms / Miss
Profession:
Home Address:
Suburb/Town:
Home: (
State/Postcode:
)
Work: ( )
Mobile:
Email Address:
Medicare Number:
Ref No/Expiry Date:
Next of Kin Name:
Relationship:
Contact Number:
How did you hear about YourHealth?
Advertisement □
Expo/Conference □
Article □
Friend/Relative/Colleague □
Pharmacy/Health Food Store □
Walk-by/Signage □
Brochure/Flyer/Poster □
Website □
Direct Mail □
Gift Voucher/Prize □
Practitioner Referral □
Seminar □
Email Newsletter □
Orion Corporate Health □
TV/Radio Interview □
General Consent Form and Authority
to Release and Obtain Information
YourHealth Manly Pty Ltd
15 South Steyne, Manly NSW 2095, Australia
Ph: 02 9977 7888 Fax: 02 9977 3436
www.yourhealth.com.au
GeneralAcknowledgement
Acknowledgement and Consent
General
ConsentForm
Form
I, _____________________________________________________________________________
of ____________________________________________________________________________
understand that some of the diagnostic tests, treatments and products administered by
practitioners at YourHealth Manly may be outside the parameters of conventional medicine in
Australia. They fall into the category of Natural or Complementary Medicine. I understand that
these diagnostic tests, treatments and products are supported by empirical knowledge, are safe,
are widely and successfully used by Integrative Medical Practitioners in centres in Australia and
overseas, and are only prescribed with utmost care. Some diagnostic tests and treatments offered
at YourHealth centres are not covered by Medicare or private health insurance funds. All
YourHealth practitioners are members and active participants of their respective professional
Colleges and Associations.
I am attending YourHealth Manly of my own free will and consent and exercise my right to discuss
and choose any useful and suitable treatment(s) made available to me. I understand that
YourHealth practitioners may recommend and dispense items that are yet to be regulated by the
Therapeutics Goods Administration (TGA), should the practitioner deem that such products or
treatments are in my best interest. If there are any risks associated with using unregulated
products or treatments, the YourHealth practitioner(s) will make me fully aware of these risks and
provide me with sufficient information to make an informed decision.
Signed,
Patient’s Name:
Witness’ Name:
_____________________________________
_____________________________________
Signature:
Signature:
_____________________________________
_____________________________________
Date:
Date:
_____________________________________
_____________________________________
Thank you for completing this form. It is designed to improve my understanding of your condition.
NAME: ____________________________________________________________________
ADDRESS: _________________________________________________________________
10 – 20
AGE GROUP (in years):
□,
21 – 35
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Is your condition affected by the weather?
26 – 50
□,
DATE: __ / __ / ____
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SEX:
F
M
PHONE: ___________________
51 – 65
□,
+ 66
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Are you BETTER or WORSE in:
DAMP/RAINY weather
DRY weather
COOL/COLD weather
WARM/HOT weather
a COOL CHANGE
before a THUNDERSTORM
in WINDY weather
Is your condition affected by physical activity?
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Are you BETTER or WORSE with:
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GENTLE MOTION
STRONG EXERTION
DOING MENTAL TASKS
REST (SITTING)
STANDING
LYING ON YOUR BACK
Are you worse at certain times of day?
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Are you BETTER or WORSE:
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AFTER SLEEP
in the MORNING
in the AFTERNOON
in the EVENING
at NIGHT
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Do you suffer much with any of the following problems:
CONSTIPATION □, LOOSE STOOLS □, a BLOATED STOMACH □, WINDY BOWELS □, VOMITING or NAUSEA □,
ABDOMINAL PAINS □, FREQUENT BURPING □, INDIGESTION □, SINUSITIS □, BLOCKED NOSE □, AN IRRITATING
COUGH □, DRY MOUTH or THROAT □, FLUSHED FACE □, BREATHLESSNESS □, RED or SORE EYES □, PAINFUL
JOINTS □, SWOLLEN JOINTS □, BACKACHE □, BACK STIFFNESS □, NECKACHE □, NECK STIFFNESS □,
HEADACHE (Specific sites): FOREHEAD □, TOP OF HEAD □, SIDE OF HEAD □, BACK OF HEAD □,
FATIGUE □, MUSCLE WEAKNESS □, SKIN RASHES □, ITCHING SKIN □, ITCHY SCALP □, RAPID WEIGHT LOSS □,
or WEIGHT GAIN
□?
(For YOUNGER WOMEN) Are you affected by MENSTRATION?
BEFORE
Are you BETTER or WORSE:
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AFTER
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Are your PERIODS: IRREGULAR (TOO FREQUENT □, or DELAYED □), TOO HEAVY □ or LIGHT □?
DURING
Are you taking any
PRESCRIBED MEDICATIONS
Yes □
CONTRACEPTIVE or HORMONAL PRODUCTS
Yes □
VITAMINS or MINERALS
Yes □
HERBAL MEDICINES?
Yes □
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If YES, please detail NAMES (& DOSES):_______________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Have you ever had any
SEVERE INFECTIONS
Yes □
Yes □
SERIOUS OPERATIONS
SERIOUS ILLNESSES
Yes □
If YES, please outline (including dates):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Have you had any
Yes □
BAD VACCINATION REACTIONS?
If YES, do you know which vaccine? : POLIO □, TETANUS-DIPTHERIA-PETUSSIS (TRIPLE ANTIGEN) □, T.B. □,
SMALL POX □, YELLOW FEVER
□, MEASLES-MUMPS-RUBELLA □, MENINGITIS □, HAEMOPHILUS (HIB) □,
HEPITITUS A □, HEPATITUS B □, CHICKEN POX □.
Have you noticed any?
INCREASED HUNGER □, LOSS OF APPETITE □, INCREASED THIRST □, LACK OF THIRST □,
□, or LOSS OF SENSE OF TASTE □ ?
(Do things taste rather BITTER □, SWEET □, FOUL □, METALLIC □ ?)
INCREASED SENSE OF SMELL □, or a LOSS of your usual SENSE OF SMELL □?
DETERIORATION in your HEARING □, or your VISION □?
SWEATING:
FOR NO REASON □, MAINLY IN THE AFTERNOON □, MORE AT NIGHT □?
FEVERISHNESS:
FOR NO REASON □, MAINLY IN THE AFTERNOON □, MORE AT NIGHT □?
INCREASED or ALTERED TASTE
Is there any associated:
ANXIETY: Due to events beyond your control
□, or Does the ANXIETY seem to come from within yourself □?
With FEELINGS of: FEAR or TERROR □, GRIEF □, SHOCK □ or ANGER □?
FAINTNESS □, VERTIGO or DIZZINESS □, POOR MEMORY □, POOR CONCENTRATION □,
MENTAL CONFUSION □, INTENSE DREAMING □, SADNESS □, or DEPRESSION □?
IRRITABILITY □, or RESTLESSNESS □, HEART PALPITATIONS □, INSOMNIA □?
WAKING IN THE EARLY HOURS □, POOR BALANCE □, UNUSUAL CLUMSINESS □,
TWITCHING or TREMORS □, NOISE in your EARS (TINNITUS) □, TOOTHACHE □,
FREQUENT PASSING of a DILUTE URINE □, or INFREQUENT PASSING of a STRONG URINE □?
WEAK SEX DRIVE □, or rather an unusually HIGH SEX DRIVE □?
Do your PALMS & the SOLES (of your feet) often have a feeling of: NUMBNESS
□, HEAT □, or COLDNESS □?
Does your SKIN have frequent sensations of: “PINS & NEEDLES” □, STINGING □, or CRAWLING □?
Is there any sensation in your CHEST of: PAIN □, OPPRESSION or HEAVINESS □, or FULLNESS □?
Presently do you generally feel
If you are TOUCHED LIGHTLY
If you are PRESSED FIRMLY
BETTER or WORSE:
□
□
If you are IN YOUR OWN COMPANY
If OTHERS ARE AROUND
If you are INDOORS
If you are OUT IN THE OPEN AIR
If you are AT THE BEACH
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BETTER or WORSE:
If you are IN A DRAUGHT
WITH A FAN ON
OUT IN THE WIND
WRAPPING UP WARMLY
UNCOVERING A LITTLE
WHILE YOU ARE EATING
AFTER EATING
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Do you have a preference for: WARM DRINKS □, WARM FOODS □, COLD DRINKS □, COLD FOODS □?
Do you have any particular: FOOD CRAVINGS: ( SWEET □, SALTY □, BLAND □, SPICY □ ),
or DRINK CRAVINGS: ( HOT □, COFFEE □, TEA □, COLD □, COLA □, SWEET □ )
Are you upset by: ALCOHOL □, DAIRY □, EGG □, NUTS □, MEAT □, SEAFOOD □, SPICES □, FATS □, ONION □?
Are you sensitive to: LOUD NOISES □, STRONG SMELLS □, or BRIGHT LIGHTS □?
Is there any unusual BRUISING OF THE SKIN □, or BLEEDING from the SKIN, NOSE, BOWEL or BLADDER □?
Do your WAIST & HIPS often feel WEAK and SORE: Yes
□? Do you often have SWOLLEN ANKLES: Yes □?
Do you suffer with ALLERGIES: Yes □? Can you be specific?:______________________________________________________
Thank you for completing this form. It is designed to improve my understanding of your child’s condition. DATE: __ / __ / ____
CHILD’S NAME: _____________________________________________________________ SEX: F □ M □
AGE:
_______ YEARS ________ MONTHS _________ WEEKS
PARENT’S NAMES: _____________________________________________________________________________
CONTACT ADDRESS: _____________________________________________________ PHONE: ______________
PRE-CONCEPTION: Were there any serious health problems in either parent at the time of the child’s conception? __
______________________________________________________________________________________________
PREGNANCY: Any health problems during the pregnancy? ______________________________________________
BIRTH: Did the birth go smoothly? (i) YES ___, (ii) YES except for _________________________________________
(iii) NO ____________________________________________________________
VACCINATION: Is your child vaccinated? (i) YES ____, NO _____
If YES, were there any problems following vaccination? NO _____, YES following _____________________________
FEEDING:
Did your child have any difficulties with cow’s milk? YES ____, NO _____.
Was a special formula necessary? YES ____ (Type:______________________________), NO ____.
Did your baby suffer much from colic ____ or wind ____? Has your child lost weight ____?
Is your child always hungry ____, or have they become hungrier recently ____?
Do you have a thirsty child ____, or do they seem to drink less than normal ____?
Does your child have a problem with the following foods: milk ____, rich food ____, ice-cream ____,
eggs ____, meat ____, sweets ____, salty food ____, fish ____, fruit ____, other ________________?
Does your child crave: egg yolk ____, or food that is sweet ____, salty ____, or spicy ____?
Drinks that are cold ____, or hot ____? Will they only eat blandly-flavoured foods ____?
TEETHING:
Were there major problems with teething ____? Have the teeth come down a little crooked ____,
or have one or two decayed ____, or been easily broken ____?
BOWELS:
Have the bowels been a problem ____? Has there commonly been constipation ____, diahorrea ____,
soft pale motions _____, a foul odour ____, pain on passing ____?
Does your child suffer with a smelly flatulence ____ or stomach cramps ____?
Was toilet-training difficult to achieve? YES ____ NO ____
GENERAL:
Does your child seem to have plenty of energy ____, or do they tire easily ____?
Are they a hot-blooded child ____, or a little chilly and cold sensitive ____?
Do they react fairly slowly ____, or do they usually do things (too) quickly ____?
Are they easily discouraged when thwarted ____, or are they persistent ____?
Is your child rather more obstinate than usual at present ____?
Have they been hurtful to their toys/pets/siblings recently ____?
Have they been somewhat indifferent to the family members around them ____?
Does your child seem forgetful ____, and has this been worse recently ____?
Have they become more irritable ____, or restless ____ in recent times?
Do they cry in the presence of strangers ____, or are they shy and quiet ____?
When upset, is your child easily comforted when being held ____, or do they get worse ____?
Are they presently touchy and easily upset ____? Are they often like this ____?
Has there been an excessive amount of jealously ____ or greediness _____ recently?
Has your child been asking for things then refusing them when offered ____?
Has your child become rather more impatient than usual ____?
Have they become more insolent ____, rude ____, or abusive ____ in behaviour?
Has your child become more critical of you in recent times ____?
Do they dislike having much clothing on ____? Are they always loosening their clothes ____?
Does your child become anxious at times without any apparent cause ____?
Are they afraid of the dark ____? Must they have a light on at night ____?
Do they become a little anxious at around sunset ____?
Is your child prone to: fainting ____, or dizziness ____, moodiness ____, sleeplessness in the evening____,
slowness to go to sleep ____, episodes of depression ____, or prolonged periods of sadness ____?
Are they easily startled by noises when awake ____, or asleep ____?
HEAD:
Does headache occur from time to time ____? Does hunger bring on headache ____?
Do headaches come on when your child is concentrating on something ____?
Does your child quickly get red around the face when exerting himself ____?
Is your child prone to sweating easily on effort ____, sweating at night ____, around the head ____,
on the face ____, on uncovered areas ____?
Are they prone to dandruff or itching of their scalp ____, rashes behind their ears ____,
swollen glands around the head or neck ____, a clear runny nose ____, a yellow/green runny
nose ____, a blocked nose ____, nosebleeds ____, hay fever ____,
scabs around the nose ____, bouts of sneezing ____, cold sores ____, mouth ulcers ____,
styes ____, ear ____ or eye infections ____?
Do they suffer much with tonsils ____, adenoids ____, pharyngitis ____, croup ____, sore throat ___?
Do the lips crack or split easily ____?
CHEST:
Is there a proneness for chest infection ____ or cough ____?
If YES, has asthma been suspected ___ or confirmed ____? Is there a family history of asthma ____?
Is their cough worse in damp conditions ____? Is your child easily upset by tobacco smoke ____?
Does cold weather bring on a cough ____, or is hot weather more troublesome ____?
WEIGHT:
Is your child overweight ____, normal size ____, or a bit undersize for age ____?
Have they been this way for a while ____, or has there been a rapid change ____>
WEATHER:
Does the weather seem to affect your child? Are they BETTER (B) or WORSE (W) in:
DAMP ____ or RAINY weather ____, DRY weather ____, or COLD weather ____,
HOT weather ____, during COOL CHANGES ____, during WARM CHANGES ____,
before THUNDERSTORMS ____, during THUNDERSTORMS ____?
TIME:
Are they BETTER (B) or WORSE (W) at certain times of day?
AFTER SLEEP ____, in the MORNING ____, around NOON ____, AFTERNOON ____,
at SUNSET ____, in the EVENING ____, at NIGHT ____?
Is there a predictable worse time ______________________________________________________?
SKIN:
Do they suffer much with any of the following:
OILY SKIN ____, DRY SKIN ____, SKIN RASHES ____, ITCHY SKIN ____, MOLES ____,
BOILS ____, THRUSH ____, RINGWORM ____, or FUNGAL infections ____?
Do they get ECZEMA behind the ears ____, on the scalp ____, on the face ____,
or on the hands ____?
Does your child have “sensitive skin” ____?
URINARY:
Does your child seem to pass urine frequently ____, or not that often ____?
Has nightmare bed wetting been a problem ____?
Is there a strong history of: ALLERGIES ____, JOINT problems ____, BACK or NECK PAINS ____, MUSCLE
PAINS____, POOR BALANCE ____, CLUMSINESS ____, GENERAL WEAKNESS ____,
SLUGGISHNESS ____, DROWSINESS ____, a STUMBLING WALK ____, REPETITIVE MOVEMENTS___?
Have they ever had any SERIOUS:
INFECTIONS__________________________________________________,
OPERATIONS_________________________________________________,
or other ILLNESSES____________________________________________
Do they generally seem BETTER (B) or WORSE (W):
IN THEIR OWN COMPANY ____, or WITH OTHERS AROUND ____?
INDOORS ____, or OUT IN THE OPEN AIR ____? AT THE BEACH ____? WRAPPED UP WARMLY ____,
or UNCOVERED A LITTLE ____? WHILE EATING ____ or AFTER A MEAL ____?
IN THEIR BED ____ or IN YOUR BED ____?
Are they sensitive to NOISE ____, STRONG SMELLS ____, or BRIGHT LIGHTS____?
Do their symptoms start SUDDENLY ____, or GRADUALLY ____? Or are they CONSTANT ____?
THANK YOU for completing this form. Please remember to bring it with you!