Download the 3 day food diary We appreciate the opportunity to serve you and ask you to assist us by completing the following questions. Name* Preferred Name* Are you under 18 years old? YesNo What are your parent's names? Address* Postcode* Phone Mobile* Work Phone Date of Birth* Age* Email* Occupation Relationship Status If in a relationship, partner's name Names and ages of children How did you hear about us? FacebookInstagramWebsiteGoogleLocationOther Who referred you to Wave? Have you ever received nutritional care? YesNo Who was your last practitioner? Your Health History About Your Life Journey The human body is designed to be healthy. Throughout the course of your life's journey you may have encountered many stressors. Whilst some of these stressors may have seemed small, they have likely had an accumulating effect on your life and health. Please answer the following questions regarding your life's journey. Pregnancy Did your Mum and Dad... Prepare their body for pregnancy? YesNoUnsure Plan and welcome the pregnancy YesNoUnsure Have a nutritious diet during pregnancy? YesNoUnsure Exercise through pregnancy? YesNoUnsure Smoke or drink alcohol during pregnancy? YesNoUnsure Endure stress during pregnancy? YesNoUnsure Have any scans? YesNoUnsure Birth Process Home birth? YesNoUnsure Hospital birth? YesNoUnsure Induced labour? YesNoUnsure Was your birth... EarlyLateOn due dateNot sure Drugs during delivery? YesNoUnsure Long delivery? YesNoUnsure Difficult delivery YesNoUnsure Caesarean (elective/emergency)? YesNoUnsure Childhood Growth and Development Physical Did you reach all your milestones? YesNoUnsure Did you have any major accidents? YesNoUnsure Did you have any surgery? YesNoUnsure Did you play childhood sports? YesNoUnsure Chemical Take medication/drugs? YesNoUnsure Were you breast-fed? YesNoUnsure For how long? first 3 monthsfirst 6 monthsfirst 9 monthsup to about 1 yearmore than 1 year Were you bottle fed? YesNoUnsure For how long? first 3 monthsfirst 6 monthsfirst 9 monthsup to about 1 yearmore than 1 year Vaccines received? YesNoUnsure Were you taught about healthy eating? YesNoUnsure Were you a fussy eater? YesNoUnsure Did you ever have an eating disorder? YesNoUnsure Emotional Was there any stress in the family? YesNoUnsure Was there a loss of a family member/relative? YesNoUnsure Was there communication breakdown in the household? YesNoUnsure If yes to any of the above, please give details Lifestyle Do you eat healthy foods? YesNoUnsure Do you smoke? YesNoUnsure Do you drink alcohol? YesNoUnsure Do you drink adequate water? YesNoUnsure Do you drink any caffeinated drinks? YesNoUnsure Are your teeth healthy? YesNoUnsure Do you sleep well? YesNoUnsure Are you physically stressed? YesNoUnsure Are you mentally stressed? YesNoUnsure Are you taking or have you ever taken drugs/medication? YesNoUnsure Do you exercise regularly? YesNoUnsure Sports/Hobbies? How would you rate your energy levels out of 10? (1 being poor, 10 being fantastic) —Please choose an option—12345678910 How would you rate your immunity out of 10? (1 being poor, 10 being fantastic) —Please choose an option—12345678910 How would you rate your clarity/focus out of 10? (1 being poor, 10 being fantastic) —Please choose an option—12345678910 General Health Weight? Height? Blood Type? Accidents? Drugs/Medications? Vaccinations in the last 5 years? Supplements? Surgery? Have you experienced a loss in the past 5 years (financial, relationship, family)? Allergies? Food Sensitivities? Health Practitioners? Family History cancer/diabetes/cardiovascular disease/other? YesNo If yes, from whom? Eating Habits Please complete the 3 day Food Diary (download available on top of this page), and email it back to us at info@wavevitality.com.au a few days prior to your initial visit. Health Goals People consult us with one or more of the following health goals. Please indicate which apply to you. Relief of my symptomCorrection of my underlying problemsTo maximise my healthTo maximise myself, my family's and my community's health You may have a specific reason for consulting WAVE VITALITY. If this is the case what are they? How would you rate your overall health, out of 10? —Please choose an option—12345678910 What would you like your health to be, out of 10? —Please choose an option—12345678910
