Welcome to our Health Questionaire Please fill in each of the questions with as much detail as possible. Name * Please fill this form out for yourself Child's Name If completing for your child fill in the information relating to the child. You may want to add relevant information about yourself/family in the extra information field at the end of the form. Contact email address * Supply an email address that is secure and confidential Age * Sex * Male Female Occupation Your present occupation and any relevant past ones Presenting Problem * Describe the problem that you are seeking advice about? Allergies Do you have any known allergies? Please list: Medical HistoryAnything about your medical history that you think is relevant for us to help you. Personal Medical History Is there anything about your medical history that would be helpful for us to know Last Fever When was your last fever (high temperature)? Accidents/Shocks Have you suffered any major accidents or traumatic experiences? Current Medications What medications are you taking at present? Previous Treatment What have you tried up until now to help with this problem? Your Childhood Immunisations Yes No Were you immunised as a child? Fevers/Illnesses Chicken pox Measles Mumps Whooping Cough Ear Infections Tonsillitis Significant events Did anything significant happen to you as a child? Family Medical History Grandparents/Parents/Siblings - any relevant health information StatisticsEnter these if you know them Body Temperature Feel the cold easily Whole body is warm Hands/feet are usually cold but rest ok Height cm Weight kg Blood Pressure Pulse/Respiration Rate Nutrition Meals - None -1 meal per day2 meals per day3 meals per day Regularity - None -I always eat at regular timesI usually eat at regular timesI never eat at regular times Fluid Intake - None -Drink water regularly during the dayDo not like water but drink other fluidsDon't need or want to drink during the day Food Preferences Meat Dairy Vegetables Fruit Cereals/Bread Sweet foods Tick the foods you choose to eat. Food Intolerances List any food intolerances you have Digestion Bowels Regular once daily bowel motions Bowel motions more than once a day Bowels do not move every day Tendency to - None -DiarrhoeaConstipationBothNeither Disturbances List any other digestive disturbances e.g. indigestion Menstrual Cycle Cycle - None -Always regularUsually regularNever regular Period: Normal Light bleeding Heavy bleeding Painful Endometriosis Pre-menopausal Menopausal Post-menopausal Obstetric history Details of pregnancies and birthing Sleep Quantity - None -less than 5 hours5-6 hours6-8 hoursmore than 8 hours Quality: Regular bedtime Bedtime varies a lot Get up at the same time Irregular due shift work Interrupted sleep Fall asleep easily Have trouble getting to sleep Frequently wake between 2am and 3 am Frequently wake between 3am and 4am Get up easily ready for the day Have to drag myself out of bed a lot Dream Sleepwalk Tick any that apply Other information Is there anything else you would like to briefly add to the information already given? Location For NZ residents we often recommend other therapies so please give the city or town nearest to you. Consultation Booking Do you wish to make a booking for an in-store consultation with our Anthroposophic Health Practitioner. Fee is $20 for 20minutes. If so please supply a contact phone number.