New Client Form Gender * Male Female Do you wish to have your appointment In-person Online/Skype Phone/FaceTime Name * First Name Last Name Date Of Birth * Address Phone * Email Address * Occupation * How did you hear about Stephanie Malouf Nutrition? * Reasons for visit / Main health concern? * How is this affecting your life? * Are you taking any medications, herbal or nutritional supplements? Please specify dosage brand and quantity if you know it otherwise please bring this info to your consultation Are there any obstacles preventing you from making changes? What kind of treatment(s) have you tried for the problem(s) listed above? Please detail any relevant testing or investigations and bring copies of the results to your consultation. What three things would you most like to improve about your health over the next few weeks? Any dietary exclusions & reasons? Eg Vegetarian or known food allergies Any diagnosed health conditions? E.g. Type 1 or 2 Diabetes, Crohn's Disease, PCOS, Rheumatoid Arthritis How would you rate your STRESS 1 = Very Low 10 = Very High 1 2 3 4 5 6 7 8 9 10 How would you rate your ENERGY 1 = Very Low 10 = Very High 1 2 3 4 5 6 7 8 9 10 Hours of sleep per night 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 Digestive System Do you regularly experience any of the following? Abdominal discomfort Constipation Diarrhoea Indigestion Reflux Bloating Nausea Flatulence Immune System Frequent Colds/Flu Frequent UTIs Frequent Infections Cold Sores Chronic Fatigue Allergies Slow wound healing Skin Rashes Itching Dermatitis Psoriasis Eczema Acne Senses Headache Dizziness/Light headed Visual Light sensitivity Blurred Vision Tinnitus (ringing in ears) Loss of smell or taste Female Health Absent or irregular periods PMS Menopause Pregnancy Low/loss of libido Neurological Health Confusion Memory Loss Altered Alertness Generalised muscle weakness Depression/Anxiety General Wellbeing Fatigue Tension/Stress Irritability/Nervousness Anxiety Sleep Problems Heart & Circulatory High blood pressure Low blood pressure Numbness in hands/feet Cold hands/feet Tingling in hands/feet Respiratory Difficulty Breathing Cough Sinus Hayfever Asthma Chronic infections Musculoskeletal Pain/Stiffness At night In the morning Arthritis Any other comments? Thank you.If you are yet to book your appointment, please contact Stephanie via email or on 0434 109 922.I look forward to working with you.
