Resources - Awaken Your Health
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Client Forms

For your convenience we have several options when completing our forms – you can complete the form online using our secure website or you can download a PDF that you are able to complete using your computer, iPad or iPhone. Once completed you have the option of submitting it using our secure upload service, a great choice for the environment that saves you having to print the form and remember to bring it with you – or if that is your preferred choice, you are able to do so. 

Health Questionnaire

To ensure you get the most from your first appointment, please complete the Client Health Questionnaire prior to your first consultation. For your convenience we have an online form or you can download the PDF, complete it and bring it along to your first appointment.

The questionnaire will take you take around ten minutes to complete. Please answer each question as completely as possible. If you should have any queries, please feel free to contact me.

Download Form

Please try to answer every question, there are no ‘right’ or ‘wrong’ answers
All of your answers will be kept confidential

Questions with an asterisk (*) must be answered or the questionnaire will not be accepted for submission

Name
Phone
Email
Date of birth
Age

Are you happy to receive AYH quarterly newsletters, including recipes and specials?

Do you have any children? YesNo

Please list the main problems you are experiencing and/or reasons for this appointment.

What do you believe the problem may be due to?

What kind of treatment(s) have you tried for the problem(s) listed above? Please detail any relevant testing or investigations and bring copies of the results to your consultation.

What three things would you most like to improve about your health over the next few weeks?


What are your long term health goals?

Do you have any existing medical conditions or injuries? If so, please list.

Are you currently taking any supplements or herbal medicines? If so, please specify dosage brand and quantity.

Are you currently taking any medications (eg anti-inflammatories/pain relief/contraceptive pill)? If so, please specify dosage, brand and quantity.

Do you have any known allergies?

How would you rate your general energy levels?

How many hours of sleep would you have each night on average?

How would you rate your daily stress levels?

What is your current weight in kg? What is your goal weight in kg?

Do you suffer from any of the following symptoms regularly?

Do you smoke? Yes If so, how many daily?

Are you an ex-smoker? Yes If so, when did you quit?

Please let us know we’re chatting to a real person *
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