Pre-Consultation Questionnaire (PCQ)

DH-NATURAL MEDICINE CLINIC – CONFIDENTIAL CLIENT RECORD

Personal Details

Full Name (required)

Street Address (required)

Suburb (required)

Postcode (required)

Postal Address (if different to above)

Email Address (required)

Home Phone

Work Phone

Mobile Phone

Fax Number

D.O.B.

Age

Weight (kg)

Height (cm)

Sex
MaleFemale

Marital Status

Partner's Name

No of children

Health Fund

Occupation

Years at this occupation

Basic description of job duties: (heavy lifting, typing, etc.)

Paediatric Patient Details

Full Name

D.O.B.

Age

Weight (kg)

Height (cm)

Sex
MaleFemale

How Did You find out about Our Clinic

Referral from family member/ friend (please provide the name below)Referral from Doctor or other practitioner (please provide the name below)Advertising / Mail OutSignWebsiteHealth Talk / SeminarNewsletter

Other:

Referrer's name:

MEDICAL HISTORY

AsthmaCancerDiabetesIDNon IDEpilepsy / SeizuresHepatitisHIV / AIDSHeart DiseaseHigh Blood PressureLow Blood PressureLeukaemiaMultiple SclerosisPoliomyelitisTuberculosisPacemakerJoint ReplacementSurgical ImplantsCar AccidentWorked With Toxic SubstancesRecent Vaccination

Drug Allergies

Other Allergies

Other Conditions

Have you been hospitalised for any other reason?
YesNo

Have you been on an overseas trip in the past two years?
YesNo

Major injuries or accidents (include dates)

Surgical operations (include dates)

Current medication and Supplements (include reasons for taking and duration)

Family History

Life Style
SmokeDrink Alcohol - please provide details belowDrugs - please provide details belowSpecial Diet - please provide details belowExercise - please provide details below, e.g. how many times per week?

Details:

Males Only

Recent Prostate ExaminationRecent Testicle ExaminationProblem Getting an ErectionProblem Maintaining ErectionPremature EjaculationDifficulty Urinating

Females Only

Pregnant - if so, enter weeks below

Weeks Pregnant

Number of Pregnancies

Number of Past Terminations

Contraception

Age at first period

Last Period

My Period is usually:
HeavyLightPainful

With my Period I also get:
PMSDischargeClotting

I am Menopausal:
YesNo

CHILDREN ONLY

Birth Order: (e.g. ... of ...)

APGAR: (... /9)

IVF
YesNo

Term of Pregnancy (weeks)

Delivery

Complications

Feed Straight
YesNo

Humidi-Crib
YesNo

If yes, how many days?

Born with hair
YesNo

Teething

Toilet Trained
YesNo

Flat Feet (Shoes Off)
YesNo

Vaccinations
Hepatitis BDiphtheriaWhooping CoughHib (Flu)MMRTetanusCervical CancerVit KGiven Panadol (for fever)

Reaction for Vaccination:

Total Courses of Antibiotics in Lifetime:

Sweats Easily/For No Reason

Hours Sleep/Night

Hours TV, etc. /Day

Sport

No. Games, Training/wk

No. Stools/Day

FirmSoftSmellFood

No. Urination/Day

Appetite

BigSmallPicky

What is your main problem or reason for seeking treatment?

On a scale of 1 to 10 (1 = no problem, 10 = worst possible), where is your problem?

Right now?

When it is at it's worst?

Where do you want it?

If not 1, why not?

What have you tried already to fix this problem?

Why did you stop?
MoneyTimeOther commitmentsDidn't work

Other reasons:

What specifically do you want from your treatment?

How will you know when you've achieved the result you're after?

When you've achieved that, how will it make you feel?

How serious are you about fixing this problem? (1 = not serious, 10 = completely)

If you scored yourself less than 7, why is that?

Treatment requires a commitment of time, energy and finances. Is someone else involved in making financial decisions about your health? Who:

Have you discussed and agreed your treatment is within your budget?
YesNo

What factors could possibly stop you from completing a recommended treatment plan?

What do you think will happen to you if you don't take action now to fix this problem?

If I can show you a simple, step-by-step way to improve your health and achieve your desired results, how soon do you want to get started?
Right awayIn a few weeksNo real rushI'm just curious for now

Imagine it's 6 months in the future. You've fixed this problem, and achieved the results you want with your health. Looking back, what would you say to yourself about your decision to have this treatment now?

Terms, Conditions, Disclaimer and Release
• I understand and accept that payment for my treatment is required at the time of service.
• I have reviewed the information on this questionnaire and it is accurate to the best of my ability. I understand that this information will be used to help determine an appropriate course of treatment.
• All information gathered in this and subsequent consultations will remain strictly confidential.
• There may be a material risk associated with this and subsequent consultations and formally consent to all physical examination, testing and treatment (for myself and/or minors under my care).
• I understand that it may be required at times to remove items of clothing (down to, but not including underwear) for the purpose of assessment, examination and treatment, and give my full informed consent for this.
• I have read, understood and agree to abide by the DH-Natural Medicine Clinic ‘Terms and Conditions'.
• I am happy to receive health related information from this practice.

Thank you for taking the time to answer these questions. Your answers will help me determine the best course of action for your treatment to help you achieve your health goals as fast as possible.