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Step 1: Create User Profile User Login Information Before you begin, we need to create a profile for you on our website. You may be prescribed one of our online nutrition programs in the future and these details are used to log into the members section of our website. Please enter your email address as a user name and create a password. You will receive an email confirming these details for your future reference.
Email:		Password:
In preparation for your initial appointment, please complete the following questionnaire. Please be assured that we respect your right to privacy, your health information and personal details are held in the strictest confidence. The information you provide here allows us to create healthcare protocols that have been specifically designed for your individual needs, so please include as much detail as possible.
Contact Information
First Name:		Surname:
Date Of Birth:		Address:
Suburb:		State:
Postcode:		Home Phone:
Mobile:
Skype Name:		Occupation:
Emergency Contact Name:		Emergency Contact Phone:
Relationship:		Name of G.P:
GP Phone Number:


How did you hear about us?	www.bondihealthandwellness.com Bondi Health & Wellness Facebook Page www.taniaflack.com Magazine Article Blog Word of Mouth Other

Who referred you?	Doctor Health Professional Friend/Family/Colleague

How Can We Help You?
What are the main health problems concerning you today?
Description:
What are your top 3 health goals? (In order of priority)
On a scale of 1-10 (1 being very poor, 10 being excellent), how would you rate your current health?

Personal Health History

(Past major illnesses, accidents or surgeries)

Family Health History

Please provide details of any significant family health problems

Relative	Age	Health problems	If deceased, cause	Age at death
Mother
Father
Sibling
Sibling
Sibling
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt/Uncle
Aunt/Uncle
Cousin
Cousin

Do you have any particular concerns relating to family health problems that you would like to prevent? Please provide details

Cancellation Fee

We require 24 hours notice if you need to cancel or change your appointment, otherwise a cancellation fee of the full cost of the appointment will apply.

Privacy Policy

We respect your right to privacy. All information you provide will be held in the strictest confidence. We will never release your health information, including pathology results, to another party without your express written consent.

Thank you! The information you supply here ensures you receive the most appropriate treatment. Your signature confirms that the information you have supplied is true and correct and that you have acknowledged and agreed to our cancellation policy.

To digitally sign this document, tick this box and enter your full name:

Digitally Signed

Full Name:

Date:

Step 1: Create User Profile

User Login Information

Contact Information

How Can We Help You?

Health Information

In a few words, please provide details on the state of your:

Female Clients Only

Current Conditions

Please tick if you suffer from:

Personal Health History

Family Health History

Cancellation Fee

Privacy Policy