First Name *

Last Name *

Date of Birth *

Gender

StatusMarriedSeparatedDivorcedWidowedSinglePartnership

Do you have children?

YesNo

If so, how many?

Do you live with:SpousePartnerParentsChildrenFriendsAlone

Occupation

Hours per week

Email Address *

Phone Number *

Address Details

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Emergency ContactName, Relationship to you & Number

How did you hear about us?

Why would you like to coach with us?

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Body FrameSmallMediumLarge

Blood Type (If Known):

HeightCentimetres

Weight Current:Kg

Lowest:

Highest:

Ideal:

What is you major complaint? Please list when each symptom began & be as descriptive as possible *

On a scale of 1-10 (1 being absolutely horrific & 10 being AMAZING), rate the following:

Your Health

Your energy

Your Emotional Health

Your Diet

Your Fitness

Your Brain Health

Your relationships

Your Finances

Your Sleep

During the past year, how many days did you miss work or have your regular activities curtailed, due to illness?

In the past 12 months, how many days were you in hospital?

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Please list all medications your are currently taking INCLUDING the condition for which it is taken, dosage & frequency. 

Add a new row for each medication

Medications

Medical Condition

Dosage Taken

How many times per day

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Please list all supplements you are currently taking INCLUDING the condition for which it is taken, dosage & frequency. 

Add a new row for each supplement

Supplement

Condition

Dosage

Times per Day

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Please describe any current or past usage or recreational drugs

Please list your current and past health conditions (ie. Diabetes Mellitis, osteoporsis, hypothyroidism)

Is there anything else in your medical history that you consider to be relevant (even from childhood)

What treatments have you tried? Has anything been successful?

Please list your past or present hobbies or leisure activities & how often are you involved in theseRecreational activities, painting, etc

Please list past or present allergies, including allergies to medications, food allergies, seasonal & environmental.

Please list all past surgeries and the condition each surgery was for, including dates

Explain your sleep (How many hours do you get, quality, how long does it take you to fall asleep, what is your typical bedtimeand wake up time, do you feel rested when you wake up, do you dream?)

When was your last dental visit?

How often do you go in for cleaning?

Do you have mercury amalgam fillings in your teeth?

YesNo

What type of health equipment have you purchased? (Eg. Sauna, hyperbaric chamber, TENS machine, etc)

Do you have issues digesting fats such as avocado, coconut oil, olive oil, cheese, etc?

YesNo

Have you had your gallbladder removed?

YesNo

Do you consume dairy?

YesNo

Do you have trouble with dairy?

YesNo

Do you have trouble with gluten or wheat?

YesNo

Do you eat gluten or wheat?

YesNo

Do you eat pork?

YesNo

Did or do you drink diet soft drink?

YesNo

Is there a diet name or type of way you eat and how long have you been eating this way?

What foods do you stay away from?

How many servings of alcohol do you consume in an average week?A serving is defined 375mL of beer, 150mL of wine or 45mL of Spirits

Do you currently use tobacco products?

YesNo

Have you previously used tobacco products?

YesNo

As a child did you eat a lot of sugar and/or candy

YesNoUnsure

How much of the following do you consume each week?

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Coffee

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Tea

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Soda

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Other Caffeine

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Dairy

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Cheese

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Bread

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Sugar

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Candy/Chocolate

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

Dessert

More than 3 times a dayOnce a dayA few times a weekOnce a weekOnce a monthNever

What is your typical daily diet *Breakfast, Lunch, Dinner, Dessert, Snacks

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General Health Questions

 

YesNo

Do you have a working carb on monoxide detector?

YesNo

Have you ever had your home tested for Radon?

YesNo

Do you have high blood pressure issues?

YesNo

Do you have low blood pressure issues?

YesNo

Do you have sweaty or clammy hands?

YesNo

Do you have any swollen or tender lymph glands, tissue or skin areas?

YesNo

Have you ever had a blood transfusion? Is so, when?

YesNo

Do you have a Smart Meter on your home?

YesNo

Have you ever had glandular fever or suspected of having glandular fever?

YesNo

Do you have bad breath (no relief by bushing)?

YesNo

Do you have body odour (no relief by washing)?

YesNo

Do you need to drink caffeine to get going?

YesNo

Have you last more than 5kgs in the last 6 months?

YesNo

Have you gained more than 5kgs in the last 6 months?

YesNo

Have you ever lived near, on or by a golf course, freeway or tension wires?

YesNo

Have you ever had any chemical exposures? (ie. cleaning chemical spills, beauty salon, etc)

YesNo

Do you have your house sprayed with pesticides for pest control?

YesNo

Do you spray weed killers in or around your home?

YesNo

Do you bug bomb your home?

YesNo

Do you use conventional insect repelants on yourself or family?

YesNo

Do you use perfume or cologne?

YesNo

Do you use aerosol hairspray?

YesNo

Do you get your nails done?

YesNo

Do you use air freshener in your house, work or car?

YesNo

Does your spouse or other family members work around chemicals?

YesNo

Can you think of any other toxic exposures you may have had?

YesNo

Does your skin have a yellowish colour?

YesNo

Do you crave sugar or sweets?

YesNo

Do you crave starches, grains, breads, carbs, etc?

YesNo

Do you crave salty foods?

YesNo

Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

YesNo

Does anyone in your family experience similar symptoms to yours?

YesNo

Do you have any history of kidney dysfunction?

YesNo

Do you or any immediate family member have a history with cancer?

YesNo

Do you have any history of heart disease, myocardial infarction (heart attack), etc?

YesNo

Are you currently having any thoughts of suicide?

YesNo

Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?

YesNo

Do you have rapid mood swings?

YesNo

Are you impatient, moody or nervous?

YesNo

Are you in a constant state of anxiety or fear? Do you excessively worry?

YesNo

Do you have difficulty making decisions?

YesNo

Do you have an inability to relax or restlessness?

YesNo

Do you have a history of stroke?

YesNo

Have you ever been diagnosed with diabetes, thyroiditis or heart disease?

YesNo

Have you ever been in an auto accident, fallen or received a major physical trauma?

YesNo

For Males Only

 

YesNo

Do you have difficulty attaining/ maintaining an erection?

YesNo

Does ejaculation cause pain?

YesNo

Do you have an underactive sex drive?

YesNo

Do you have an overactive sex drive?

YesNo

Do you have issues with premature ejaculation?

YesNo

Do you have pain or coldness in the genitl area?

YesNo

Do you have infertility issues?

YesNo

Do you have discharge from the penis?

YesNo

Do you have lack of early morning erections?

YesNo

Do you presently or in the past have a rash on your penis?

YesNo

Do you have swollen genitals?

YesNo

Do you have swelling in the groin?

YesNo

Do you have genital sores?

YesNo

Do you have a mass or lump in the scrotum?

YesNo

So you have jock itch?

YesNo

Have you ever had a sexually transmitted disease?

YesNo

Do you use any prescriptions for improving sexual function?

YesNo

Have you ever used HCG, DHEA or hGH?

YesNo

For Females Only

 

YesNo

Are you in or did you go through perimenopause or menopause?

YesNo

Do you get hot flashes/night sweats?

YesNo

Do you have a history of missed periods?

YesNo

Do you have pelvic or vaginal soreness or pain?

YesNo

Do you have menstrual pain?

YesNo

Do you have heavy menstrual bleeding?

YesNo

Do you have infertility issues?

YesNo

Do you have an under active sex drive?

YesNo

Do you have an overactive sex drive?

YesNo

Do you have monthly weight gain?

YesNo

Do you get bloating or swelling?

YesNo

Do you have tender breasts?

YesNo

Do you have vaginal itching?

YesNo

Do you have vaginal discharge or sores?

YesNo

Do you have vaginal dryness?

YesNo

Have you ever had a sexually transmitted disease?

YesNo

Do you dislike intercourse?

YesNo

Do you have pain in ovaries?

YesNo

Do you get water retention?

YesNo

Do you have a history of miscarriages?

YesNo

Do you have a history or ovarian cysts?

YesNo

Do you have a history of uterine cysts or fibroids?

YesNo

Do you have a history of endometriosis?

YesNo

Have you had a hysterectomy?

YesNo

Have you ever taken oestrogen, progesterone, testosterone, DHEA or hGH?

YesNo

Microbiome and Digestive Health

 

YesNo

Do you often have gas that has a sulphur or foul smell?

YesNo

Do you get heartburn or reflux?

YesNo

Are you sensitive to supplements?

YesNo

Have you ever been vegan or vegetarian for any length of time?

YesNo

Can you tolerate meat?

YesNo

Do you have a history of using anti-acids, proton pump inhibitors or anything that blocks acid?

YesNo

Do you currently or have you used hormone replacement therapy?

YesNo

If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

YesNo

Have you been on antibiotics in the last year? If so, how many rounds?

YesNo

Does your gut temporarily feel better after a round of antibiotics?

YesNo

Do you have a history of antibiotic use as a child or adult?

YesNo

Were you caesarean delivered (aka C-section)

YesNo

Do you have a history of cold sores, warts or skin tags?

YesNo

Have you gotten food poisoning before?

YesNo

Do you have skin issues?

YesNo

Do you have a history of athlete's foot or foot fungus such as on toenails?

YesNo

Do you have a history of jock itch or vaginal yeast infections?

YesNo

Does skipping a meal greatly affect your symptoms?

YesNoUnsure

How many Bowel movements do you have per day

Do your bowel movements have a tendency to be more

Harder (Constipation)Looser (Diarrhoea)

Do you have symptoms immediately after eating, such as belching, bloating,sneezing, hives, etc

YesNoUnsure

How many courses of antibiotics have you taken in the last year

How often have you taken oral steroids

When you were born, were you

Full term?Premature?

If premature, how early?

Were you

Breastfed?Bottle Fed?

For how long?

Mental Health

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

YesNoUnsurePrefer not to talk about this

Have you or your family recently experienced any major life changes?

YesNoUnsureYes, but prefer not talk about this

Have you experienced any major losses in life?

YesNoUnsureYes, but prefer not to talk about this

Did you feel safe growing up

YesNo Unsure

Have you been involved in abusive relationships in your life?

YesNoUnsurePrefer not to talk about this

Have you ever had psychotherapy or counselling?

YesNo

How would you rate your current level of stress (1 being low 10 being extreme)

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Do odors affect you?

YesNo

Which odours and how do they affect you

Do you exercise regularly

What type of exercise?

Why do you believe you would be a good candidate to work with Shelley VanBarneveld

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