Health & Wellbeing Assessment Form

Mel is so looking forward to your first appointment!
To help her get a better understanding of where you are currently are in your health journey,
please complete the following form.

If you would prefer to complete this form in paper form,
you can download the Health Assessment Form here.
Once you have completed your form, please scan and email the form to melinda.mcmahon [@] gmail.com

To allow adequate time for Mel to prepare for your appointment,
please ensure your completed form is received 24 hours before your scheduled appointment.
** PLEASE DO NOT BRING YOUR COMPLETED FORM TO YOUR APPOINTMENT **

Please be reassured your responses will be handled with the strictest confidence.

Full Name

Please enter your full name.

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Phone Number

Enter your contact phone number.

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Date of Birth

Please state the date in full.

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Email Address

Please enter a valid email address.

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Address

Your full residential address.

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Emergency Contact Name

Please provide the name of an emergency contact.

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Emergency Contact Phone Number

Phone number of your emergency contact.

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Let’s talk about your health goals …

Primary Health Goals

What are your primary health goals?

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Primary Health Concerns

List your primary health concerns.

Let’s talk about your sleep …

Sleep Habits Overview

Describe your sleep habits and feelings about your sleep. Do you wake up often during the night? Do you have troubles going to sleep? Do you share a bed with a partner?

Children (if any, please list ages)

Do you have children? If so, please list their ages.

Let’s talk about your support community …

Household Support Overview

Who lives in your home and who helps with meals and shopping?

Support for Health Goals (1-10)

How supportive are people around you of your health goals? (1) Being little support & (10) being tremendous support

This field is required.

Exercise Habits

What are your normal exercise habits?

Typical Diet Description

Describe your typical diet.

Please indicate your chosen dietary pattern:

Omnivore | Meat, vegetables & fruit

Vegetarian | Dairy Products & eggs

Vegan | No animal products

Standard Ausssie Diet

Food Allergies or Intolerances

Do you have any food allergies, intolerances, or sensitivities?

Smoking Habits

Do you smoke?

Yes

This field is required.

Alcohol Consumption

Do you drink alcohol?

Yes

This field is required.

Let’s talk about your medical situation …

Medical Conditions

Has a doctor diagnosed you with any medical conditions?

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Current Medications

List any current medications you are taking.

Supplements

What supplements do you take?

Medical History Overview

Briefly summarize your medical history.

What about fasting …

Experience with Intermittent Fasting

Have you tried Intermittent Fasting?

Never! I need to eat regularly

I've only fasted for medical reasons

Yes I restrict when I eat

I have a regular fasting protocol

Nutritional, Hormonal or Toxicity Tests

Have you undergone any nutrition, blood, hormone or heavy metal testing?

Yes

Traumatic Experiences

Have you had any traumatic experiences in your life?

Daily Stress Level (1-10)

Rate your typical stress level on an average day.

This field is required.

Stress Coping Mechanisms

How do you normally cope with stress?

Let’s explore your metabolic health

Please select which of these you regularly experience:

Do you struggle to lose weight?

Have you been on multiple calorie restriction diets in your life?

Are the weight loss tricks you used to use no longer working?

Have you been gaining weight even though you haven’t changed anything with your diet or exercise plans?

Did you gain belly fat when you went into menopause?

Do you get ‘hangry’ if you go without food?

Do you need food when you first get up in the morning?

Do you need to eat every few hours to keep up your energy?

Do you get sleepy after you eat?

Do you get brain fog after you eat?

Do you crave sugar?

Do you crave alcohol?

Do you forget to eat enough vegetables?

Have you been on 5 or more rounds of antibiotics in your life?

Have you been diagnosed with high blood pressure?

Are you currently taking one of the weight loss drugs?

Are you over 40 years old?

Are you post menopausal?

If you have a cycle, is it regular?

If you know your blood work numbers, is your HgA1c above 5?

Let’s check your Toxic Load ..

What about your dreams …

Do you dream regularly? What about re-occurring dreams or nightmares?

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Finally …

How READY are you to change your behaviours and habits?

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What are the biggest obstacles preventing you from achieving your health goals?

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