SECTION 1: For Completion by Patient

    Personal Details

    Lifestyle

    Medical History

    Please indicate if you have been diagnosed with the following conditions, or have had any of the following procedures:

    Musculoskeletal/Injury:

    Detail:

    Cardiovascular:

    Respiratory System:

    Nervous System:

    General:

    Gastrointestinal:

    Renal:

    Family History

    Please provide details if applicable:

    High Cholesterol

    High Blood Pressure

    Angina

    Heart Attack

    Stroke/TIA (mini-Stroke)

    Asthma/COPD

    Hemochromatosis

    Cancer Related Diseases

    Other Conditions (please Specify)

    Medications & Allergies

    Medication

    Allergies

    Do you have allergies or sensitivities to:

    Pain & Skin

    Pain

    Skin

    Social History, Alcohol & Drug Use

    Social History

    Alcohol & Drug Use







    Physical Activity, Sleep & Stress

    Lifestyle Factors

    Mental Wellbeing (Last 2 weeks)

    How often have you been bothered by:

    Dietary Information

    Food Habits

    Fluid Intake







    Sexual Health

    For female participants:

    For male participants:

    *A copy of all your results will be shared with your general practitioner*