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Form – Blood Test

HEALTH QUESTIONNAIRE

Patient Profile

Personal Details

Occupation &Interest

GP Details & Records

Medical History

Personal History

Medication & Allergies

Family History

Current Health

Smoking & Alcohol

Physical Health

Mental Health

General Health

Typical Diet

Reason of Visit

Ongoing Consent

Patient Consent

First Name *

Surname *

Gender *MaleFemale

Date of Birth *

Address *

Suburb *

State *

Postcode *

Nationality *

Home Phone Number *

Mobile Phone Number *

Email Address *

Are you an Aboriginal or Torres Strait Islander?YesNo

Occupation *

Address *

Suburb *

State *

Postcode *

Work Number *

Work Email Address *

Secondary Work Email (if applicable)

Interests - Hobbies, sport, social events etc.

Name of your GP *

Address *

Suburb *

State *

Postcode *

Blood Pressure

Beats P/M

Weight (kg) *

Height (cm) *

Contact Number of your GP *

Medicare Number *

Expiry Date *

Reference Number *

Upload files (medical reports, scans, etc)

Drag and Drop (or) Choose Files

Past Surgery Detail(s) - Please include ALL surgeries

Year of Surgery

Surgery

Past Medical Detail(s) - Please include any work related injuries and claims

Year of medical treatment

Related injuries and claims

Past Medications(s)/Nutrients - Please list ALL script medications, vitamins, minerals, herbals, etc.

Dosage

Time

Medication

Allergy Detail(s) - Please list ALL allergies to medications, vitamins, minerals, herbs, food, etc.

Allergies

Past Family DetailsPlease indicate whether there is a history of the following conditions in your family: heart disease, high blood pressure or circulatory conditions, cancer, diabeties osteoarthritis ankylosing spondylitis, rheumatoid arthritis, multiple sclerosis, muscular dystrophy, mental ilness, auto-immune disorders, asthma, allergies, psoriasis, eczema, alcoholism, drug abuse or any other conditions that are pertinent to your present state of health.

Year

Details

Do you smoke? *YesNo

If Yes, how many per day?

Have you smoke in the past? *YesNo

If Yes, what year did you quit?

Do you drink? *YesNo

If Yes, how many units per week?

In the past 12 months, have you had any weight gain? *YesNo

If Yes, how many kgs?

In the past 12 months, have you had any weight loss? *YesNo

If Yes, how many kgs?

Between 0-10 (excellent), how would you describe you current physical health? *012345678910

Lowest at what time?

AMPM

Time *

Between 0-10 (excellent), how would you describe you current energy levels? *012345678910

Highest at what time?

AMPM

Time *

Typically, how often do you exercise per week? *Never1-2 Days3-4 DaysDaily

What exercises are part of your typical routine? *

Do you need a Fitness Coach for training guidance? *YesNo

Between 0-10 (excellent), how would you describe your mental health? *012345678910

Do you need a Psychologist for mental guidance? *YesNo

Please indicate what is impacting your mental health?

What is your typical diet throughout the day?

Breakfast

Time

Breakfast

Brunch

Time

Brunch

Lunch

Time

Lunch

Afternoon Tea

Time

Afternoon Tea

Dinner

Time

Dinner

Before Bed

Time

Before Bed

Do you need a Nutrition Coach for nutrition guidance? *YesNo

What is the main condition or symptom(s) you would like us to help with?Please list when you first noticed the condition and describe carefully what you suspect may have played a role.

Condition or Symtoms

What are your major goals you would like us to help with?Please list any queries or concerns that may restrict you from achieving these goals.

Goals

Terms and Condition

I hereby confirm that “HUMAN PERFORMANCE HEALTH CLINIC ”, has fully explained to my absolute satisfaction all aspects negative and positive regarding my specific Peptide treatment. I hereby also confirm that I am completely satisfied with the opportunity that has been presented for me to have all of my related questions regarding but not limited to the treatment and alternative treatments answered. I have been specifically informed to the level that I completely understand and agree without compromise the following:

1. I solemnly swear that I have provided and told HUMAN PERFORMANCE HEALTH CLINIC everything to the best of my knowledge about my medical and or family medical history, if I experience an adverse effect due to misreading information, intentional and or unintentional direct or indirect, aware or unaware

I hereby authorize the HUMAN PERFORMANCE HEALTH CLINIC ACN: 661 451 065 medical team and staff to perform examinations and/or treatment deemed necessary. I declare that I am over 18 years of age and I am over 18 years of age and I am NOT under any sporting or professional code where the treatments or medicines offered are probihited.

Patient Signature *

Start signing your signature here

Date *

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Contact us

Our customer support team are experienced medical professionals and will advise on any condition with the upmost care and confidentiality. Talk to us today.

1300 014 742
info@hphealthclinic.com.au

1300 014 742

info@hphealthclinic.com.au

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Full Name

Phone

How can we help you?

Designed and Developed by

Welcome to Human Performance Health Clinic!

Health Screening Assessment

What category of treatment are you looking for?

What is the desired goal of the treatment you are looking for?

Do you have any health issues?

Do you have any allergies?

Do you smoke?

If so, how regularly?

Do you drink alcohol?

If so, how regularly?

Do you take any medications or hormone therapy?

Do you have any Injuries?

Is there anything else you would like to tell us prior to discussing with the team?

First Name

Last Name

Phone

I consent to receive the PDF and additional research via email, phone, SMS, or other electronic means from Human Performance Health Clinic. By checking this box, I acknowledge that I have reviewed and accepted the Terms & Conditions and Privacy Policy of Human Performance Health Clinic. I also agree to be reached out to concerning the results of the quiz and for other informational and promotional purposes.