(02) 6882 2322
Home
Client Login
Contact Us
Menu
Who We Are
Who We Are
Our Team
Services
Services
Initial Consultation
Follow-Up Consultation
Weekly Food Workshops
Food Coaching Packages
Online Appointments
Gut Health Consultation
What We Treat
What We Treat
Digestive Health
Optimal Weight
Autoimmune Conditions
Children's Health
Optimal Mood
Cancer Recovery
Chronic Health
Healthy Hormones
Diagnostic Testing
Health Education
Corporate Health
Free Info
Questionnaire
*
Required
Title
DR
MISS
MR
MRS
MS
Date of Birth
*
Email Address
*
First Name
*
Last Name
*
Parent or Guardian (For Children Only)
Home Address
*
City
*
State
*
Zipcode/Postcode
*
Country
*
-- Select Country --
AUSTRALIA
Home Phone Number
Work Phone Number
Cell Phone Number
Doctors Details
*
Private Health Fund
*
Height (cm)
*
Weight (kg)
*
Next of Kin
*
Relationship
*
Phone Number
*
How did you hear about Macquarie Natural Health? Please tick the category below.
Advertisement
Article
Brochure / Flyer / Poster
Email
Facebook
Friend / Relative
Gift Voucher
Pharmacy / Health Food
Practioner Referral
TV / Radio
Walk By Signage
Website
Other
If Other (Please Specify)
General Details
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?
*
When was the last time you felt truly well?
*
What do you expect from your consultation today?
*
What do you think can help you?
*
CHILD Only
Child Information
Sleep Pattern - Please give details
Caesar birth? (Yes/No)
Breast Feed? (Yes/No - if so please include duration)
Formula Feed? (Yes/No - if so please include details)
Symptoms
Please include:
Yes/NO & Relevent Age
.
Reflux
Colic
Skin Condition
Skin Condition
Urinary tract Infection
Ear Infection
Respiratory Infection
Oral thrush
Hospitalisation
Tunes out / Daydreams
Complains of Tummy Discomfort
Hyperactive
Attention Deficient
Excessive flatulance
Fatigues easily
Poor short term memory
Bad breath
Irritable
Sugar craving
Poor motor skills
Itching
Hard to fall asleep
Smelly stool(poo)
Mood swings
Aggressive
Anxious
Fungal Infection
ADULTS & CHILD
NUTRITIONAL SUPPLEMENTS, HERBAL MEDICINES, HOMOEPATHIC REMEDIES
CURRENT MEDICATIONS (prescription and non-prescription)
ALLERGIES/SENSITIVITIES (including medications, foods, dust mites, grasses, chemicals)
Diet
Do you follow a specific diet?
Yes
No
If yes please specify.
ADULTS Only
Occupation
Marital Status
Cigarettes/Tobacco
Alcohol
Recreational Drugs
Exercise
Relaxation Techniques
FEMALE Only
Menopausal
Peri-menopausal
Regular cycle
Irregular cyce
Do you use contraception
Do you have children
Are you pregnant
Are you breastfeeding
Number of pregnancies
Prove you're not a robot
*
Macquarie Natural Health
Home
Who We Are
Health Education / Community Involvement
Corporate Health
Client Login
Free Info
Contact Us
Services
What we treat
Digestive Health
Optimal Weight
Autoimmune Conditions
Children's Health
Optimal Mood
Cancer Recovery
Chronic Health
Healthy Hormones
Diagnostic Testing
Standard Pathology Screening
Urinary Organic Acids
GPL-Tox: Toxic Chemical Profile
Food Sensitivity Testing
Microbial Stool Testing
DUTCH Hormone Testing
Pfieffer Screening & Pyrrole Testing
DNA Wellness Profiles
