Health History — Qi By The Sea

Email

Date, time (if known) and place of birth

day/month/year

Height and weight

Marital Status

Do you have a particular issue or something specific you would like to explore?

Please give as much detail as possible.

Occupation and hours of work per week

Please describe your reason for selecting the above

Please share details of any hospitalisations and/or serious illnesses

If not applicable, please state 'Not applicable'

Please share any medications and/or supplements you are currently taking or have regularly taken in the last 10 years

Please detail reasons for the medication. If not applicable, please state "Not Applicable"

Please share past or present use/consumption and frequency of the following: tobacco, alcohol, marijuana (or any other drug)

If not applicable, please state 'Not applicable'

Please describe your reason for selecting the above

Please detail how many hours you sleep per night approximately

Please also indicate whether you wake up during the night, if so, how often and generally for what reason?

Please detail any allergies or sensitivities

If not applicable, please state "Not Applicable"

Please describe if applicable, or if post-menopause, please detail date of last period

Please describe your reason for selecting the above

Please also indicate what, if any activity you participate in, and for how long and how often.

Please describe your reason for selecting the above

What are you most worried about when it comes to your wellbeing?

FOR ONLINE CLIENTS: Please offer a minimum of three different dates and times you would be available for a 60 minute Zoom call.

I'm in New South Wales, Australia and work in Australian Eastern Standard Time (AEST). Please specify your time zone and whether dates given are in your timezone or AEST.

Anything else you would like me to know?

How did you hear about me?

Health History.