Sandra's Health Hub

Client consultation form

Please complete this form before your appointment so Sandra can understand your health history, current concerns, and the support you are seeking.

All information provided is treated as strictly confidential.

Personal details

Basic client and contact information.

Date *

Family name *

Given name *

Date of birth *

Age

Occupation

Postal address *

State *

Postcode *

Phone *

Email *

Marital status

Children and ages

Primary concerns

Your goals, symptoms, and reason for treatment.

Any fertility, pregnancy, or labour issues?

Reason for seeking treatment, expectations, and desired outcome *

When did symptoms start, how long have they been going on, and what makes them better or worse?

Medical background

Medication, history, and broader care context.

Medication, dosage, and how long you have been taking it

Medical history, operations, accidents, serious illnesses, hospital visits, vaccinations, and any lasting side effects

Are you currently under the care of any other health care professionals?

Body systems

Please list any disorders, how long you have had them, how often they occur, and whether symptoms worsen at certain times of day.

Skeletal

Muscular

Respiratory

Urinary

Sinus, eye, or ear

Headaches

Digestive

Circulation

Reproduction

Lifestyle

Food, hydration, habits, movement, and sleep.

Yesterday's food consumed

Was this a fair representation of your normal diet?

Tea, cups per day

Coffee, cups per day

Alcohol, drinks per day

Water, glasses per day

Milk, glasses per day

Fruit juice, glasses per day

Do you smoke? If yes, how many per day, and do you want to quit?

History of or current recreational drug use

How often do you exercise and what type?

Sleeping patterns

Family and emotional health

Relevant family history and current emotional state.

Family history of mother, father, and siblings

Fears or phobias

Current stress or worry, and what about it feels stressful

How do you feel in yourself?

Consent and declaration

Please read carefully before submitting.

Printed name *

Date *

Digital signature *

Squarespace code embeds do not provide a true handwritten signature field on their own, so this uses a typed digital signature.

I have read and understood the declaration above and consent to treatment. *