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Health Assessment Questionnaire Call 09 444 4527 for an appointment

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Health Questionnaire

Please fill out the below Health Questionnaire so that I can get an understanding of your current health needs, and how best to help. If you would prefer to fill this out by hand, please click the button below to download a printable copy of this form.

"*" indicates required fields

Please note that all information provided is strictly confidential and will not be disclosed to anyone without your permission.

Name*

Date of First Visit

DD slash MM slash YYYY

Address*

Phone*

Email*

Occupation

Date of Birth*

MM slash DD slash YYYY

Height

Weight

Main Reason for Visit

Existing Conditions

What are your main health goals? (List in order of priority)

(Click the + icon to the right of the field to add more list items)

Please list all current medications you are taking:

(Click the + icon to the right of the field to add more list items)

Please indicate in the fields below any suppliments (if any) you are curently taking.

(Click the + icon to the right of the field to add more list items)

Brand

Name of Product

Dosage per Day

Have you had any medical exams, tests, x-rays, radiation or chemotherapy in the last 5 years?

Yes

No

Please specify:

Have you ever had any surgical operations?

Yes

No

Please specify:

Lifestyle Factors

Do you drink alcohol?

Yes

No

Do you smoke?

Yes

No

Roughly how many glasses of water do you drink each day?

Do you drink Coffee?

Yes

No

Occasionally

How many cups?

Do you drink Tea?

Yes

No

Occasionally

How many cups?

Do you drink Juice?

Yes

No

Occasionally

How many cups?

Do you drink Fizzy Drinks?

Yes

No

Occasionally

How many cups?

Do you take part in any form of exercise during the week?

Yes

No

Please state the type of exercise and how long your sessions are:

Please list any foods you:

Have an intolerance to

Avoid

Crave

What would a typical day look like with regards to food eaten?

Weekday Breakfast

Weekend Breakfast

Weekday Lunch

Weekend Lunch

Weekday Dinner

Weekend Dinner

Weekday Snacks

Weekend Snacks

Comment

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Phone

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1A/16 Saturn Pl,
Albany, Auckland 0632
P: 09 444 4527
E: info@simplygreathealth.co.nz

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