Patient Intake Form – Global Health Clinic

Global Health Clinics – Patient Intake Form

Please complete all pages and click Submit button.

Personal Details

First Name

Last Name

Address Line 1

Address Line 2

City

Region

Zip Code

Country

Gender

D.o.B

Age

Phone/Mobile

Ethnicity

Marital Status

Occupation

Guardian's Name (if client a child)

Height Weight

No. of Children

General Practitioner

I have read and agree to the Terms and Conditions and Privacy Policy I agree to undergo consultation with a practitioner at Global Health Clinics, or with our authorized locum, on the following terms. All personal information gathered from me will be kept confidential under the privacy Act, and any other laws of New Zealand. I agree information being used, anonymously, for the purpose of advancement of knowledge, for example for teaching or as statistical data. I maintain the right to refuse any examination or treatment that i do not wish to have. I agree that i will make every attempt to comply with any treatment i do accept, or i will discuss the reasons for this with the practitioner or with GHC management. Global Health Practitioners make well being assessments according to holistic scientific principles. Global Health Clinics use holistic lifestyle methods to assist clients to regain or improve their health. Global Health Clinics, or an authorized locum do not make medical diagnoses, nor makes a claim to "cure" medical diseases. We will not attempt to interfere with or recommend changes to medical treatment prescribed by a medical doctor. Global Health Clinics practitioners use every care with the quality and appropriateness of nuraceutical preparations and therapies, i accept that, very rarely, there may be unexpected reactions. In that situations, i accept full responsibility for any adverse reactions and will inform my practitioner at the earliest possible time. I take personal responsibility for my well being and for the treatment and ongoing maintenance with the support of Global Health Clinics, its practitioners and authorized locums. I accordance with legal requirements, I absolve Global Health Clinics and its practitioners from adverse reactions arising from non-disclosure of any medication or medical conditions.

Practitioner to Fill : Blood Oxygen Levels

Date

SPO2 %

HR: BPM

Coh %

Initial Questions

Please fill in this questionnaire so we can establish what your health and well being priorities are. As a Holistic well being practice, we see health and well being as a mind-body-spirit issue and the information given here will help your practitioner formulate a specific treatment plan for you to achieve your health and well being goals.

How did you find out about Global Health Clinics?

Why have you come to Global Health Clinics?

Have you ever had similar challenges before, and if so, when?

List any daily activities you are finding difficult, or are limited as a result of this issue(s) :

Please list any other healthcare professionals you are seeing for this or other problem(s). Please give their names and modality:

How satisfied are you with these practitioners? (1 not satisfied, 10 very satisfied)

1 2 3 4 5 6 7 8 9 10

How satisfied are you with your current GP? (1 not satisfied, 10 very satisfied)

1 2 3 4 5 6 7 8 9 10

Please list any medical tests or scans you have had in the last 12 months:

What are your goals from consulting Global Health Clinics practitioner(s)?

List any prescribed medication that you are currently taking or have taken regularly in the past and for what reason/condition?

List any natural dietary supplements that you are currently taking or have taken recently:

Health Professionals & Medications - Health History

Past medical history (previous injuries, accidents, surgeries, traumas, loss of consciousness, childhood illnesses, cataract etc. Please describe and include approximate dates:

Have you got a history of mental illness or addiction. Yes/No please specify

IMPLANTS (Yes/ No)- Hip, Knee, Heart, Breast, Eye, Other

Check any vaccinations you have had (Immunizations):

Polio Influenza Meningitis Tuberculosis Tetanus Hepatitis A/C Triple Vaccination Diptheria/Whooping Measles/Mumps/Rubella Cough/Tetanus

Tonsillectomy

Yes No

Other Vaccines(Specify):

Do you have a history of :

Mental illness Addiction Emotional traumas Cancer Heart disease Diabetes Arthritis Asthma/Eczema Relationship conflict/Divorce Adoption

Does your Family Member(eg: parent or sibling) have a history of :

Mental illness Addiction Emotional traumas Cancer Heart disease Diabetes Arthritis Asthma/Eczema Relationship conflict/Divorce Adoption

Were you Breast-Fed?

Yes No

For How Long? (Example : Months)

Would you see your Outlook as :

Religious Spiritual Agnostic Atheist Scientific

Womens Health

Menstrual Cycle

Regular Irregular

Do you get PMT?

Always Sometimes Never

What type of contraception do you use?

About Menopause are you?

Pre-menopausal Peri-menopausal Post-menopausal

Mens Health

How many times do you get up at night to urinate?

0 1 2 3 4 More

Is urination painful?

Yes No

General Information

ow do you rate your sleep? (Poor=1; Excellent=10)

1 2 3 4 5 6 7 8 9 10

Do you suffer ongoing depression? (Poor=1; Severe=10)

1 2 3 4 5 6 7 8 9 10

How do you rate your energy on scale? (Poor=1; Excellent=10)

1 2 3 4 5 6 7 8 9 10

Are you continually tired or under-par? (Never=1; Severe=10)

1 2 3 4 5 6 7 8 9 10

How many bowel movements do you pass daily on average?

Less than 1 1 2 3 4 5 More

What do you do to relax?(Example: Hobbies, Meditation, Etc)

How much time do you have for yourself to relax?( Example : Hours/Per Week)

Feelings and Emotions

Rate any of these feelings you have experienced in the last few months:? 1 (not at all) to 5 ( extreme)

Abused

1 2 3 4 5

Criticized

1 2 3 4 5

Overworked

1 2 3 4 5

Paralysed

1 2 3 4 5

Depressed

1 2 3 4 5

Rejected

1 2 3 4 5

Despaired

1 2 3 4 5

Helpless

1 2 3 4 5

Hopeless

1 2 3 4 5

Paranoid

1 2 3 4 5

Overwhelmed

1 2 3 4 5

Muddled

1 2 3 4 5

Persecuted

1 2 3 4 5

Guilty

1 2 3 4 5

Easily Irritated

1 2 3 4 5

Anxious

1 2 3 4 5

Sad

1 2 3 4 5

Grieving

1 2 3 4 5

Unable to Grieve

1 2 3 4 5

Apprehensive

1 2 3 4 5

Agitated

1 2 3 4 5

Uneasy

1 2 3 4 5

Disstressed

1 2 3 4 5

Fearful

1 2 3 4 5

Impatient

1 2 3 4 5

Intimidated

1 2 3 4 5

Restless

1 2 3 4 5

Panic

1 2 3 4 5

Intolerant

1 2 3 4 5

Uncertainty

1 2 3 4 5

Aggravated

1 2 3 4 5

Annoyed

1 2 3 4 5

Angry

1 2 3 4 5

Outraged

1 2 3 4 5

Nervous

1 2 3 4 5

Worried

1 2 3 4 5

Exercise, Stress and Pain Information

What kind of exercise do you do?

How long do you spend per day? ( Eg: Hours)

How many times per week do you do this?

Please mark best description for level of stress:

Family Stress

None Minimal Moderate Severe

Relationship Stress

None Minimal Moderate Severe

Work Stress

None Minimal Moderate Severe

Financial Stress

None Minimal Moderate Severe

Health Stress

None Minimal Moderate Severe

Other Stress

None Minimal Moderate Severe

Do you have pain? How severe? (None=0; Unbearable=10)

1 2 3 4 5 6 7 8 9 10

Where is your pain?

Head Neck/shoulders Arms/hands Back Chest Abdomen Hips Legs/feet

What type of pain is it?

Muscular Joints Visceral/organs Nerve Other

Please provide more details about your pain:

Your Current Diet Sheet

Are you...?

Vegetarian Vegan Coeliac Gluten Free

On a Special Diet

Breakfast: (please specify if missed how many times per week)

MID AM

Lunch

MID PM

Dinner

Supper ( If any) :

Please indicate amounts of the following per day/week as frequency determines:

Coffee

Alcohol

Soft Drinks/Energy drinks(Please Specify):

Marijuana:

Chocolate:

Sugary Snacks/Lollies/Junk Food :

Cigarettes:(rollies/manufactured)

Quality of PURE water drunk daily(if at all):

Deep Fried Foods:

Pan Fried Foods:

Stir Fried Foods:

Red Meats:

White Meats:

Fish Meals:

Vegetarian Meals:

Practitioner Notes:

Date

Practitioner

Session Notes

Observations