Please provide as much information as possible on what you would like to discuss.

Welcome to ProHealth 1! To help prepare for your consultation and make the most of your appointment time, please fill in the following details as best you can:

-----------------------------------------
REASON FOR TODAY'S VISIT
-----------------------------------------
What is your main concern today?

When did it start?

Is it getting better, worse, or staying the same?

Have you tried anything for it so far (e.g. medications, home remedies)?

On a scale of 1-10, how much is it affecting your daily life?

-----------------------------------------
YOUR MEDICAL BACKGROUND
-----------------------------------------
Do you have any ongoing medical conditions? (e.g. diabetes, asthma, high blood pressure)

Have you had any surgeries in the past?

Do you have any allergies? (medications, foods, or other)

-----------------------------------------
CURRENT MEDICATIONS
-----------------------------------------
Please list any medications, vitamins, or supplements you are currently taking (include dose if known):

-----------------------------------------
FAMILY HISTORY
-----------------------------------------
Any significant conditions that run in your family? (e.g. heart disease, cancer, diabetes)

-----------------------------------------
LIFESTYLE
-----------------------------------------
Do you smoke? Yes / No
Do you drink alcohol? Yes / No - If yes, how much per week?
Do you use any recreational substances? Yes / No

Occupation:

-----------------------------------------
FOR TODAY'S CONSULT
-----------------------------------------
Is there anything specific you are hoping for today? (e.g. prescription, referral, test results, medical certificate, general advice)

Have you seen another doctor about this concern? Yes / No
If yes, what was the outcome?

Preferred pharmacy (name and suburb):

-----------------------------------------
Thank you for completing this! It helps us provide you with the best care possible.

Indijah Bullman Psychologist

Info

Fees/Services