FORM INTRODUCTION

VENUS HEALTH ACADEMY

CLIENT CONSULTATION FORM

FORM INTRODUCTION

Please complete this form in as much detail as possible before your consultation. The information you provide helps us build a clearer picture of your current health, lifestyle, nutrition, daily routine and overall wellbeing.Helen will review this information with you during your consultation.The information provided through this form is for holistic health education and consultation purposes. It does not replace medical diagnosis, treatment or advice from your GP, consultant or another appropriately qualified healthcare professional.Your information will be treated confidentially unless you have given express permission for it to be shared with another person or practitioner.This form is expected to take approximately 15-20 minutes to complete. Please ensure you complete it before your consultation to make the most of your appointment time.

PERSONAL DETAILS

SECTION 1: PERSONAL DETAILS

Full Name *

Email Address *

Phone Number *

Date of Birth

Age

Address

Occupation

Emergency Contact Name

Emergency Contact Number

Relationship of emergency contact to you

CONSULTATION DETAILS

SECTION 2: CONSULTATION DETAILS

What is the main reason for booking this consultation? *

What are your main health concerns at present? *

How long have you been experiencing these concerns?

When did you first notice that something did not feel right with your health?

Was there anything happening in your life around the time your symptoms began? Examples may include illness, infection, bereavement, pregnancy, menopause, surgery, medication changes, prolonged stress, relationship changes, work pressures or major li...

Have your symptoms changed or progressed over time?

Have you received a diagnosis from a doctor or specialist?

Yes No

If yes, please provide details of any diagnosis or diagnoses.

Have you had any recent blood tests, scans, investigations or medical reports relating to your health concerns?

Yes No

If yes, please provide details and approximate dates.

MEDICAL HISTORY

SECTION 5: MEDICAL HISTORY

Do you have any current or previous medical conditions?

Yes No

If yes, please provide details.

Have you ever had surgery?

Yes No

If yes, please provide the type of surgery and approximate date.

Have you ever been admitted to hospital?

Yes No

If yes, please provide details.

Are you currently under the care of a doctor, consultant, specialist or other healthcare professional?

Yes No

If yes, please provide details.

MEDICATIONS

SECTION 7: MEDICATIONS

Are you currently taking any prescribed medication?

Yes No

If yes, please list each medication, dosage, how often you take it and why it was prescribed.

Are you currently taking any over-the-counter medication?

Yes No

If yes, please provide details.

Have any of your medications recently been started, stopped or changed?

Yes No

If yes, please provide details.

SUPPLEMENTS, HERBS AND NATURAL PRODUCTS

SECTION 8: SUPPLEMENTS, HERBS AND NATURAL PRODUCTS

Are you currently taking any supplements, herbs, vitamins, minerals or natural remedies?

Yes No

If yes, please list everything you currently take. Where possible include the product, dose and frequency.

Have you ever had a reaction to herbs, supplements, medication or foods?

Yes No

If yes, please provide details.

ALLERGIES AND INTOLERANCES

SECTION 9: ALLERGIES AND INTOLERANCES

Do you have any known allergies?

Yes No

If yes, please list them and describe the reaction if known.

Do you have any known or suspected food intolerances or sensitivities?

Yes No Unsure

If yes or unsure, please provide details.

PHYSICAL ACTIVITY AND MOVEMENT

SECTION 14: PHYSICAL ACTIVITY AND MOVEMENT

How often do you exercise or intentionally move your body?

Daily Several times per week Once per week Occasionally Rarely Never

What type of exercise or physical activity do you do?

Approximately how long are your exercise sessions?

Do pain, fatigue, breathlessness or another health concern limit your ability to exercise?

Yes No

If yes, please explain.

ANYTHING ELSE WE SHOULD KNOW

SECTION 19: ANYTHING ELSE WE SHOULD KNOW

Is there anything about your health, lifestyle, personal circumstances, cultural background, diet or wellbeing that has not been covered in this form but which you feel is important for us to know?

Is there anything you particularly want to make sure we discuss during your consultation?

PERMISSION AND CONFIDENTIALITY

SECTION 20: PERMISSION AND CONFIDENTIALITY

Confidentiality Agreement

AGREEMENT 1 *

I understand that the information I provide through this form will be treated confidentially unless I give express permission for Helen to share information with a friend, relative, colleague, healthcare professional or another practitioner.

AGREEMENT 2 *

I understand that my Venus Health Academy consultation is intended to provide holistic health education, lifestyle and wellbeing support and does not provide or replace medical diagnosis, medical treatment or emergency medical care.

AGREEMENT 3 *

I understand that I should continue to follow the medical advice and prescribed treatment given to me by my GP, consultant or other qualified healthcare professional and should discuss any proposed changes to prescribed medication with them.

Do you give permission for Venus Health Academy to contact you regarding your consultation and related health support?

Yes No

Client Signature *

Date *

THANK YOU NOTE

Thank you for completing your Venus Health Academy Pre-Consultation Form. Your answers will help us prepare for your consultation and use your appointment time more effectively.

VENUS HEALTH ACADEMY

CLIENT CONSULTATION FORM

FORM INTRODUCTION

SECTION 1: PERSONAL DETAILS

SECTION 2: CONSULTATION DETAILS

SECTION 3: CURRENT HEALTH STATUS

SECTION 4: CURRENT SYMPTOMS

SECTION 5: MEDICAL HISTORY

SECTION 6: FAMILY HEALTH HISTORY

SECTION 7: MEDICATIONS

SECTION 8: SUPPLEMENTS, HERBS AND NATURAL PRODUCTS

SECTION 9: ALLERGIES AND INTOLERANCES

SECTION 10: DIGESTIVE HEALTH

SECTION 11: DIET AND NUTRITION

TYPICAL DAY OF EATING

SECTION 12: DAILY ROUTINE

SECTION 13: SLEEP

SECTION 14: PHYSICAL ACTIVITY AND MOVEMENT

SECTION 15: LIFESTYLE

SECTION 16: STRESS AND EMOTIONAL WELLBEING

SECTION 17: WOMEN'S HEALTH – IF APPLICABLE

SECTION 18: YOUR HEALTH GOALS

SECTION 19: ANYTHING ELSE WE SHOULD KNOW

SECTION 20: PERMISSION AND CONFIDENTIALITY

Confidentiality Agreement