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Client Intake Form
Contact details
First name
Last name
Email
Address
Phone
Birthday
Day
Month
Year
Emergency contact name
Emergency contact telephone number
Name of Doctor
Doctors address
Phone
Are you:
Female
Male
Health and health history
Reason for choosing QBT
How long have you had this issue or these issues?
How does it impact on your life?
Are you currently under the care of a doctor?
Yes
No
If yes please give details including any prescription drugs
List all supplements currently taking (also please send photos via Signal, Telegram or WhatsApp, including of nutrition panel on packaging):
Please provide any past or present medical diagnosis (given by a certified medical professional) including date or year diagnosed:
Please detail any support you have received in the past in this area e.g. from your GP, consultant, occupational health, counsellor, and/or health practitioners, etc:
Please give any details of hospitalisations, surgeries, significant illnesses or injuries (including what for and date):
Are you scheduled for surgery and if yes, please say when?
What is your Height and Weight?
Do you have a pacemaker
Do you have any metal implants (plates or screws or hip or knee replacements)? If yes please state which.
If you have had any major traumas in your life please give details below including how it has impacted you.
What other interventions have your tried already? What worked and what didn't work?
Do you have any mercury fillings? If yes how many do you have?
Do you previously had mercury fillings and had them removed? If yes how many and when?
When did you last have to take antibiotics?
Have you recently had any tests done like cholesterol? If yes please give results or if you have photos please send to your practitioner via WhatsApp, Signal or Telegram.
Do you have a family history of heart disease, cancer, diabetes or any other chronic or congenital issues?
Are you physically active?
Yes
No
If you answered yes, what sort of activity/exercise do you do and how often?
On a scale of 1-10 how much energy do you have (where 1 is very little and 10 is so much)?
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 how much energy do you have (where 1 is very little and 10 is so much)?
1
2
3
4
5
6
7
8
9
10
How many litres of water do you drink a day?
Do you drink coffee? If yes, how many?
Do you drink tea? If yes, how many cups a day?
Do you drink soft drinks/diet drinks or energy drinks? If yes, how many a day and what types?
How many times per week do you have a bowel movement?
Indicate what increases your stress levels?
Work
Family
Social
Financial
Health
Home setting
Other (please give details)
What helps you unhide/relax?
How many hours sleep do you get at night?
Less than 3
3-4 hours
5-6 hours
7-8 hours
8 plus hours
Other (please give details)
Does this feel like it's enough for you, ie do you wake up rested?
How many hours do you spend on screens a day (including for work, so laptop/computer, tablet, phone and television)?
Less than 3
3-4 hours
5-6 hours
7-8 hours
8 plus hours
Other (please give details)
Do you smoke or vape?
Yes
No
I used to
If you stopped smoking/vaping, how long ago did you stop and how many did you have a day?
If you currently smoke or vape, how many do you have a day?
Do you drink alcohol
Yes
No
If your answer was yes, how many drinks do you usually have a week?
1-3 units a week
4-10 units a week
10+ units a week
Other (please give details)
Do you follow any special diet or have diet restrictions for any reason, (for instance low fat, no gluten, no dairy, low carb, vegetarian, gluten free, high protein, vegan, weight lost, low sodium, carnivore, pescatarian, low fodmap)? Please give details.
Please give any details of food allergies, sensititivies or intolerances as well as any tests done, that have not already mentioned?
Based on how you eat on a regular basis, please check all that apply.
Fast eater
Eat in front of a screen like television
Erratic eater
Emotional eater (when stressed, bored, sad, etc)
Late night eater
Do not plan meals/menus
So busy I rely on ready meals
Love to eat
Eat too much
Eat because I have to
Eat alone
Please tick any that apply
Do you feel guilt or remorse when you eat?
Are you in fear of being overweight?
Do you isolate so you can eat?
Do you avoid eating when you are hungry?
Do you continue to eat even after feeling full?
Do you take medication or exercise instead of eating?
Do you weigh yourself at least once a day?
Do you evaluate yourself based on body size and shape?
Do you eat large amounts of food in a small amount of time
Do you make yourself vomit to avoid gaining weight
Do you take diuretics or laxatives to loose weight?
Do you hide food?
Do you feel food controls your life
Option 14
Option 15
Womens Health
Are you pregnant or could you be pregnant at the moment
Yes
No
Are you trying to conceive?
Do you use birth control? What method do you use if you do?
Are your periods regular, length of cycle, any bleeding between cycles?
Any current symptoms (Eg pms, cramps, breast tenderness, headaches,, nausea, water retention)?
Are you
Perimenopausal
Menopausal
Postmenopausal
Any current symptoms of peri menopause, menopause, post menopause (eg hot flashes, night sweats, mood swings)? If your
Is there anything else you would like to share?
Submit
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