Valeriya Zakharova

Acute Appointment Form

Please fill & submit this form prior to your appointment adding as much information as possible to utilize this service to its full potential.

Thank you!

First name

Last name

Phone

Birthday

Day

Month

Year

Address

List all your current medications and supplementations. Mention the time of the day you take these.

What is the main reason for your visit?

What are your symptoms? Add as much detail as possible.

What treatment have you had in relation to this issue up to date?

Were there any recent events that you think have contributed to your symptoms. Please list all (e.g., recent infection/vaccination, surgery, increased stress, trip overseas etc.)

What are your current Energy levels? Rate this from 1 to 10 (10 being the highest energy)

Do you have an Energy Slump during the day/evening?

Yes

How are you currently Sleeping? Do you fall asleep easily? Do you wake up during the night? Do you wake up refreshed?

What are your current Stress levels? Rate this from 1 to 10 (10 being the highest stress e.g., panic attack)

How often do you feel irritable/frustrated?

Daily

Weekly

Once a month or less

How often do you feel apathetic/lethargic/depressed?

Daily

Weekly

Once a month or less

Other

How often do you experience racing thoughts, dwelling on a situation or expressing compulsive behavior?

Daily

Weekly

Once a month or less

Do you experience brain fog, concentration and memory issues?

If you are a female, please describe your recent cycle (mention length, heavy/light flow, clot size, mood changes, etc.) Please ignore this section if you are a male - N/A.

How frequent are your bowel motions (e.g., daily)? Do you find it easy to pass the stool? Do you feel completely empty?

Do you experience excess bloating/gas/burping?

Yes, daily

Yes, when I eat the "wrong" food

No, my tummy is happy

What is your current diet? Mention some food choices you have made over the last few weeks. What is for Breakfast, Lunch and Dinner?

How much water are you currently drinking? Is it tap water or filtered?

How much coffee do you drink per day? Mention strength, milk or no milk, sugar and time of the day you drink it.

How much alcohol do you drink per week? Mention the type and time of the day you drink it.

Have you been consuming soft drinks & desserts? What type, time and how frequently?

Have often do you exercise per week? What type of exercise is it?

Current weight KG

Current height CM

Add any other information that you think is relevant.

Add any recent blood tests if relevant

File upload

Policy

It's important for us to collect your personal information before any consultation with you, so we can provide the best service at our practice.

Your personal information will be held confidentially in electronic record and in a manner that reasonably protects it from misuse and loss and from unauthorised access, modification or disclosure. Personal information will only be used for medical services and for payments, otherwise we will consult you for your consent.

Your personal information will not be disclosed with any third party without full disclosure with you. We will explain the reason beforehand, and will only share it with your consent.

There are some exceptions to disclose without your consent and that includes where we are required or authorised by law; this may include to prevent a serious threat to a patient's life or safety or to someone else's life, or if we are unable or it is impractical to obtain the patient's consent.

We will not use your personal information in any direct marketing without your consent. Appointment confirmations are not considered marketing communications.

Do you accept this policy?

Yes

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Day

Month

Year