Test - BalanSoul | George Parker

Pre-Consult v2

Consultation Booking Form

First Name

Surname

Address

Address Line 1

Apt, Suite, Bldg. (optional)

City

State / Province / Region

Zip Code

Country

Phone(Home)

Phone(Business)

Date / Time

Place Of Birth

Weight (kgs)

Height (cms)

Gender

Male

Female

Others

How many children

Current GP

Specialist

Occupation

PRESENTING SYMPTOMS:

Major health Complaints OR major health symptoms OR both Major health Complaints OR major health symptoms OR both

HISTORY OF CURRENT MEDICAL CONDITION/S

High blood pressure

pressureDiabetes (Type 1 or Type 2)

Thyroid condition (underactive / overactive)

AsthmaAutoimmune condition (please specify)

Cardiovascular disease (heart attack, stroke, etc.)

Chronic pain condition (fibromyalgia, arthritis, etc.)

Cancer (current or past)

Other diagnosed conditions (please list):

CURRENT MEDICATIONS

(list and include strength and dosage)

CURRENT SUPPLEMENTS

(list: vitamin, herbal etc and include brand name, strength and dosage where possible)

TEST RESULTS? Include copies where possible

Browse

Pathology Reports

Do you have access to your latest (and past) pathology results from your doctor?

Yes

Would you like help obtaining them?

Yes

Note:If yes, a consent form will be provided so we can request these for you.

Family Medical History

Mother

Father

Maternal Grandmother

Paternal Grandfather

Maternal Aunts / Uncles

Paternal Grandfather

Paternal Aunts / Uncles

Mood & Cognition

Allergies and Intolerances (please indicate)

Dairy products; Soy products; Yeast; Wheat; Gluten; Starch; Sugar; Tomatoes; Artificial flavours; Colourings;Alcohol; Metal jewellery; Bandaids; Cleaning products; Dust mites; Grasses; Pollens; Fur; etc

Reactivity screening

Do you notice strong reactions to any of the following?

Sulfur-containing foods (garlic, onions, eggs, broccoli, cauliflower, cabbage)

Alcohol (flushing, headache, nausea from small amounts)

Vitamin supplements (especially B6 or folate)

Histamine rich foods (wine, cheese, fermented foods, sauerkraut, vinegar, etc

What kind of reaction occurs? Please explain:

Environmental & Detoxification Sensitivities:

Do you notice strong reactions to any of the following? (tick all that apply):

Perfumes / fragrances

Cleaning products

Paints or solvents

Cigarette smoke

Pesticides or herbicides

Mould exposure Other (please specify):

Detoxification Questions

“Do you experience symptoms from everyday chemicals (e.g., perfumes, cleaning agents, petrol fumes)?”

Yes

“Do you tolerate caffeine well?”

Yes

Gut History

Diet Diary - Typical Weekday

Breakfast

Morning tea

Lunch

Afternoon Tea

Dinner (include dessert)

Snacks (what and when?) (include dessert)

How many cups of coffee, tea, or caffeinated drinks do you consume daily?

Soft drinks: cans/glasses per week

Energy drinks: cans per week

How many alcoholic drinks do you consume per week (on average)?

How many glasses of water do you drink daily (approx.)?

Extra Food Diary details(Please add here if no room above)

Lifestyle & Environment(Diet:)

Average sleep hours/night (Number)

Smoking

Yes

If Yes, specify

Relaxation practices

Yes

If Yes, specify

Environment context

Yes

Diet

Dairy Free

Yes

Allergy Testing

Yes

If so. Results?

Any foods you avoid that cause problems?

Any foods that you crave/must have?

Verification

Please enter any two digits

Example:12