NEW PATIENT QUESTIONNAIRE...to deal with specific health concerns. State Postcode/Zip Country Full Name ... the counter medications. Please include dosage, brand and reason for taking:

NEW PATIENT QUESTIONNAIRE

Please take the time to accurately complete this form.This will enable our time together to be more efficient and targeted.

Date

By completing this form, you understand, acknowledge and agree that:

• all information on this form and during any subsequent consultations is true and correct to the best of your knowledge.

• You acknowledge that failure to provide information about your current or past health may compromise the quality of health care and the treatment provided.

• You agree to inform your practitioner (Kate Smyth) of any changes to your current• medical/health condition, including any new medications (pharmaceutical, herbs, vitamins or

other supplements), pregnancy status (if female), new injuries or diagnosed/undiagnosed med-ical conditions.

• All personal details and records captured on this form and shared during consultations will be stored safely. This information will be kept confidential and will not be released to any other person without written consent, unless required by law.

• A copy of the Athlete Sanctuary’s Privacy Policy and Terms & conditions are available on the website www.athletesanctuary.com.au

• The Athlete Sanctuary is unable to give a professional opinion regarding health via email or telephone. General enquiries may be answered by telephone, but an appointment is necessary to deal with specific health concerns.

Postcode/ZipStateCountry

Full NameDate of Birth AgeStreet Address Town/Suburb

Preffered Contact Number

Preferred E-mail (where correspondence will be sent)Occupation

Emergency Contact

In Relationship to Me

General Physician’s Name Phone

Phone

NameSpecialist ( Sports Medicine G.P., Oncologist, Endocrinologist, Etc.)

Phone

What are you coming to see the Athlete Sanctuary for?

Is there anything specific that you would like us to provide?

E.g. Help with managing my digestive system

E.g. Suggestions on diet management of my condition

THE ATHLETE SANCTUARY | NEW PATIENT QUESTIONNAIRE 01


MEDICATIONS:


Current pharmaceutical medications including contraception and over the counter medications. Please include dosage, brand and reason for taking:

NAME DOSAGE PER DAY REASON

Current nutritional supplements, herbs, homeopathic medicines orflower essence. Please include dosage, brand and reason for taking:

NAME DOSAGE PER DAY REASON

When was your last course of antibiotics?

What was the antibiotics for?

YES

NO

Have you had any blood tests or other diagnostictests completed in the past 6 months? (please bring these along to your consultat ion)


MEDICAL HISTORY:

FAMILY HISTORY:


EVENT / ILLNESS AGE

If so please list

Known allergies or intolerances?

YES

NO

I have more to add to my list of event/illnesses

Main Life Events / Illnesses

Do you have any diagnosed medical conditions

For example:

• Childhood asthma age 6-18 years• Recurrent respiratory infections age 12-15 years• Divorced age 30 years• Stress fracture left shin 35 years• Loss of loved on 55 years

Has anyone in your family (mother, father, aunty, uncle, grandparents, siblings or children) been diagnosed with a major illness? Such as cancer, heart disease, thyroid issues, mental health issue, alzheimer’s disease, arthritis, high blood pressure, high cholesterol or other)

Please list

YES NO

YES NO


DIGESTION / GASTROINTESTINAL SYSTEM


Reflux

Bloating/Fullness

Discomfort/Pain in the abdominal region

Nausea

Vomiting

Flatulence

My stomach feels unsettled when I am stressed

I am a gut thinker

Constipation

Diarrhea

Fluctuating between diarrhea and constipation

Anorexia, bulimia or other Obsessions with some food

Burning sensation

Gnawing feeling between meals

Mucous in stool

Blood in stool

Recent change in appetite

Low appetite in the morning

Anal itchiness

Pale and/or floating stool

Pain on voiding stool

YES NO

Do you currently (in the past two weeks) or have a tendency to experience any of the following symptoms?

How often do you move your bowels each day?

Overseas travel in past 12 months and to what destination?

Food poisoning in the past 3 months YES NO


NERVOUS SYSTEM


Anxiety

Depression

Mood changes

Headaches

Migraines

Excessive sweating

Dizziness/Light-headedness

Numbness/tingling

Seizures

I need to exercise in the morning to feel energized

I feel “flat“ on a rest day from exercise

I suffer from post-traumatic stress disorder

I have lost a loved one in the past 6 months

Loss of memory/concentration

Have you experienced long periods of stress levels?

Current stress level (10 very stressed, 1 not stressed at all)

Quality of sleep currently (10 excellent, 1 poor)

Difficulty getting up in the morning (don’t really wake up until 10am)

Changes in sleep quality or pattern

Number of hours of sleep per night (average)

Broken sleep?

Why?

Wake feeling rested?

Current energy level out of 10 (10 bouncing out of skin, 1 exteme fatigue)

I usually feel my best after 6PM

History of high alcohol intake (> 6 standard drinks per night)

History of current and/or substance use

YES NO



EAR, NOSE, THROAT AND RESPIRATORY

IMMUNE


Ringing in the ears

Seasonal allergies/hayfever

Sinus pain/congestion

Coughing/wheezing

Shortness of breath

Ear aches

Blocked nose/sinuses

Gingivitis

Gums bleed easily

Oral thrush

Itchy eyes

Phlegm

Asthma

Amalgam fillings

Recurrent mouth ulcers and/or gum infections

Change in ability to taste

Raised Glands

Recurrent chest infections

Thrush

Bacterial Vaginosis

Cold sores

Urinary Tract Infections

I have environmental/chemical or mold sensitivities

I get cougs/colds

Other immune issues:

YES NO

YES NO




SKIN / HAIR / NAILS

CIRCULATION / CARDIOVASCUVVLAR / RESPIRATORY SYSTEM


Acne

Eczema

Psoriasis

Rashes

Itching skin

Skin redness

Darkened skin around armpit or

skin creases in other parts of body

Loss of pigmentation in skin

Slow wound healing/ulcers

Excessive skin dryness

Brittle/dry hair

Noticeable Hair loss

Brittle nails

Bruise easily

Any yellowing of skin or eyes?

History of anemia or low iron

Hemmorroids

Varicose veins

High blood pressure

High cholesterol

Heart palpitations or racing heart

Wheeze

My ankles or feet are sometimes swollen

YES NO

YES NO




MUSCULOSKELETAL

GENITOURINARY SYSTEM


Chest pain

Shortness of breath

Cold hands/feet

Reduced tolerance to exercise

Severe fatigue or dizziness with exercise

Joint pain

Muscle cramps

Back pain

Arthritis

Muscle pain

Brokern bones/stress fractures

Eyebrow twitching

Major injuries

Other musculoskeletal issues?

History of urinary tract infections

Painful urination

Increased frequency

Decreased output

Blood in urine

Kidney stones

YES NO

YES NO

YES NO




ENDOCRINE SYSTEM

FEMALES ONLY


Sugar cravings Time:

Severe fatigue Time:

Decline in visions (not age related)

Energy decline after meals

Weight gain in past 12 months Gain in kg:

I have gained weight around my middle

Weight loss in the past 12 months Loss in kg:

I get “angry“ when I haven’t eaten for a while

I feel better after fasting

Currently pregnant

How many weeks gestation:

History of miscarriage/pregnancy loss

How many weeks gestation:

Age of first period

Current or previous se of the contraception pill

IUD

Implants

Irregular menstrual cycles

Spotting between periods

Pain mid cycle

PMS

Breast tenderness

Breast lumps

Heavy periods

YES NO

YES NO




MALES ONLY


Painful periods

Lower back pain during periods

Infertility of unknown cause

History of any STDs

Post menopause

Low libido

Vaginal dryness

Hot flushes or night sweats

Hair growth or darkening of facial hair or on other parts of body

Date of last pap smear:

Date of last breast examination:

Low libido

Inability to obtain/maintain morning erection

General erectile dysfunction

Prostate issues

History of any STDs

Date of last prostate examination:

YES NO

YES NO



GENERAL INFORMATION

DIETARY ANALYSIS


I am concerned about my current weight

Do you follow a specific diet?

Do you have any food allergies?

Do you crave sugary foods?

Do you crave salt?

Do you crave any other foods?

Do you crave dirt or ice?

Do you feel like you have enough cookingskills and knowledge?

How many takeaway meals do you have each week?

Do you cook your food at homeand how often?

Do you skip meals?

Inbody or Dexa scan completed in last 3 months?

If you answered YES, please bring copy of the test results on your initial appointment

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

why?

Current Height (cm) Current Weight (kgs)

If you skip meals,please state whichones:

If so which ones

Please list:

Details:


24-HOUR FOOD RECALL


(Please record what you have eaten for the past 24 hours and provide as much detail as possible including brand and amount of food item). E.g. Breakfast 1 cup of quick oats, ½ cup full cream A2 cow’s milk, 1 medium banana and 1 cup black instant coffee

Pre training AM (If applicable) :

Breakfast :

Snack :

Snack :

Dinner :

Desssert :

Total fluids per day (including coffee/ tea, water, alcohol, soft drinks, energy drinks, sports drinks etc: E.g. 6 cups water, 3 beers and 4 cups of coffee) :

Lunch :



Do you consume the following at least once per day or on a regular basis?

How many hours on average per week do you exercise?

At what level do you compete (recreation/club, state, national, international) ?

How many high intensity sessions do you complete per week?

If you are a retired athlete, how many years ago did you retire?

Name of Coaches Phone / email

How many training sessions do you complete thatare over 90 minutes in duration per week?

What form of exercise do you do?

Alcohol

Smoke cigarettes or marijuana

Take recreational drugs

Coffee, tea, coke or energy drinks

Sports drinks

Protein bars or premade protein drinks

EXERCISE AND LIFESTYLE

ATHLETES ONLY (please complete if applicable)

Do you enjoy exercise?

Are you a competing athlete?

Do you have a coach?

How many KMs do you cover per week?

YES NO

YES NO

YES NO

Running Cycling Rowing



ATHLETES ONLY

CHILDREN’S HEALTH

(continuation)

(please complete only if the appointment is for a person under 18 years of age)

Do you travel regularly in your chosen sport?

Is the child breastfed?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

vaginal birth/normal C-section

When was your last major event?

When is your next major event?

When was your last rest period of more than a week?

When were solid foods introduced?

Has your child taken any antibiotics and how many courses?

Any behavioral changes or challenges?

Does your child have any learning difficulties?

Is your child a fussy eater?

Does your child have any sleeping difficulties?

Did your child have any complications during birth?

Did your child have any complications during pregnancy?

If Yes, what were the complications?

If Yes, what were the complications?

If Yes, how long were they breastfed for?

How was your child born?

Event

Event

Documents

NEW PATIENT QUESTIONNAIRE...to deal with specific health concerns. State Postcode/Zip Country Full Name ... the counter medications. Please include dosage, brand and reason for taking: