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Home
Weight Loss
Digestive Health
Work With Me
Functional Lab Tests
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Testimonials
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Contact Us

Initial Health Questionnaire

Initial Health Questionnaire

Please fill in our initial health questionnaire below.

Step 1 of 5

20%

Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mainly for phone/Skype clients if I need to post referrals or supplements
Date of Birth*
Age*
Male/Female*
- Male
- Female
Height in cm
Needed for face to face clients to program the scales.
If under 18, what's your guardian's name?

How many times a week do you eat fish?*
Do you smoke?*
- Yes
- No
How many a day?
How many alcoholic beverages do you consume in a week?*
Do you exercise regularly?*
- Yes
- No
On average, how many hours a week?*
Do you regularly engage in any of the following exercises?*
- Walking
- Running
- Swimming
- Biking
- Yoga/Pilates
- Gym
- Other
- I don't exercise

Please list your main health concerns in order of decreasing severity (starting with the worst one)*
On a scale of 1 to 10 (10 being the most important), how important is it to you to resolve these issues in the next 3 to 6 months?
Who or what do you think is your biggest obstacle to achieving your health goals?
What other methods, diets etc have you tried? What didn't work for you and why?
Do you have any other commitments that would keep you from being 100% successful in accomplishing your goals?

What major illnesses or health complaints have you suffered in the past?
What surgery, if any, have you had in the past?
Do you have a family history (parents, grandparents or siblings) of any of the following conditions?
- Diabetes
- High Cholesterol
- Heart Disease
- High Blood Pressure
- Cancer
- Arthritis
- Alzheimer's
- Osteoporosis
- Other
- None
Other - please specify
Do you often take antibiotics? When was the last time?
Please list any prescriptions or over the counter medications you are currently taking and what you are taking them for?
Please list any supplements you are currently taking and what you are taking them for?
Do you have any allergies or reactions to chemicals, foods, the environment (pollen, dust etc), medications or supplements? How severe?
On a scale of 1-10 (with 10 being extreme), how would you rate your level of stress?
On a scale of 1-10 (with 10 being outstanding), how good do you feel your diet is?
List the 3 worst foods you eat during an average week.
List the 3 healthiest foods you eat during an average week.
On a scale of 1-10 (with 10 being outstanding), how do you rate your health and fitness?
What is your current weight?
What is your ideal weight?

Heading
Please take 5 minutes to complete this section. Tick any items that you are currently or regularly suffer from.
Digestion
- Excessive burping/belching
- Constipation
- Alternating constipation/diarrhoea
- Bad breath
- Flatulence (gas)
- GERD (reflux)
- Bloating (distended abdomen)
- Cramping/pain
- Haemorrhoids
- Frequent use of antacids
- Coating on tongue
- Foul smelling stools or gas
- Nausea
- Vomiting
- Regular use of laxatives
- Gallbladder removed
Female Hormones
- PMS
- Dysmenorrhoea (painful periods)
- Hot flushes
- Infertility
- Urinary incontinence
- Low sex drive
- Cramping/pain
- Amenorrhoea (no periods)
- Pregnant
- Breast feeding
- Peri-menopause
- Going through Menopause
- Post menopause
- Taking the pill
- Other hormone therapy
- PCOS
- Endometriosis
- Vaginal yeast infections
Male Hormones
- Impotence / erectile dysfunction
- Low sex drive
- Difficulty urinating
- Pain / burning during urination
- Dripping after urination
Mood / Sleep
- Anxiety
- Depression
- Headaches
- Migraines
- Insomnia
- Difficulty going to sleep
- Difficulty staying asleep
- Early waking
- Irritability
- Nervousness
- Mood swings
Cardiovascular
- Raised blood pressure
- High cholesterol
- Irregular heart beat
- Dizziness when standing
- Heart/chest pain
- Palpitations/racing heart
- Varicose veins
- Poor circulation (cold hands and feet)
Skin
- Psoriasis
- Eczema
- Hives
- Acne
- Dry skin
- Dandruff
- Athletes foot
- Rosacea
- Warts/verucas
Respiratory
- Hayfever
- Allergies
- Post nasal drip
- Asthma
- Difficulty breathing
- Regular colds/flu
- Sinusitis
- Nose bleeds
- Sore throat
- Bronchitis
Metabolic
- Fluid retention
- Frequent urination
- Excessive thirst
- Cravings for sweets
- Tired if you miss a meal
- Tired after eating
- Chronic fatigue
- Need coffee to get started
- Poor concentration
- Gain weight easily
Other
- Urinary tract infections
- Ear infections
- Sinus infections
- Viral issues
- Yeast / Fungal issues
- Parasites
- Bacterial infections
- Joint pain
- Muscle pain
- Dizziness/vertigo
- Back pain

Quick Links

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Additional Resources

Long Term Weight Loss Solutions
Detoxing for Health
Help for IBS Symptoms
Fatigue & Adrenal Exhaustion
SIBO Testing & Treatment
Stress Management
How to Beat Food Cravings
Stop Chocolate Cravings
Reduce Heart Disease Risk Naturally

Get In Touch!

1300 16 75 72

32 Delhi Rd North Ryde NSW 2113

support@vibrantnutrition.com.au

Book a FREE Strategy Session

Initial Health Questionnaire

Once you've booked in for an Initial Consultation or you've joined one of my programs, please complete the questionnaire below.

Click Here To Start Your Initial Health Questionnaire

* Disclaimer: Results may vary from person to person

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