First Name *

Last Name *

Date of Birth *

Gender

Status

Do you have children?

YesNo

If so, how many?

Do you live with:

Occupation

Hours per week

Email Address *

Phone Number *

Address Details

Street address

City

State

Postcode

Emergency ContactName, Relationship to you & Number

How did you hear about us?

Why would you like to coach with us?

Body Frame

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?

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

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

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

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

General Health Questions

For Males Only

For Females Only

Microbiome and Digestive Health

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)

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

HI Thrive AI Health Coaching Consent

Healthy Innovations uses HI Thrive, an AI-assisted health coaching platform, to support your care between appointments. Please read and respond to each item below before signing.

I understand that HI Thrive uses artificial intelligence (Claude AI by Anthropic) to assist in drafting my personalised health plan, and that all AI-generated content is reviewed and approved by Shelley Van Barneveld before I receive it. *

I consent to my consultations being recorded and transcribed using Fireflies.ai for the purpose of preparing my health plan. I understand I can decline recording at any time without affecting my clinical care. *

I understand that my health data is stored securely on Australian servers and is not sold or shared with third parties. *

I understand that HI Thrive is a health coaching support tool and does not replace the clinical judgment of my registered health practitioner. *

I confirm I have read the Healthy Innovations Privacy Policy at www.healthyinnovations.com.au/privacy-policy *

Do you consent to participating in HI Thrive AI-assisted health coaching? *

Yes — I consentNo — I do not consent at this time

Signature Required *

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