Specialised Therapeutic Food Coach Patient Questionnaire

Patricia Edwards Patient Questionaire

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of birth*
Place of birth*
Referred by
Phone 1*
Phone 2
Email*
Occupation*
Weight*
Height*
Gender*
Marital status*
Number of children
Ages*
What is the main reason for consulting me?*
Using key works only, How do you feel?*
Health history past and present diagnosis, operations. List in detail:*
What prescription drugs or supplements are you currently taking?*
How are your energy levels?*
Do you have a formal exercise plan*
- Yes
- No
Please detail your weekly routine*
Do you smoke?*
- Yes
- No
How many per day*
How long have you smoked?*
Do you drink alcohol?*
- Yes
- No
How often and what?*
Do you drink soft drinks?*
- Yes
- No
Diet
Please list what you eat and drink during your normal daily diet.
Arising
Breakfast
Mid morning
Lunch
Mid afternoon
Dinner
After dinner
How many cups of tea do you drink daily?*
How many cups of coffee do you drink daily?*
Do you have milk with your tea or coffee?*
How much sugar or sweetener do you have?*
How many cups of water do you drink per day?*
Health
How many bowel movements do you have per day?*
Do they feel complete or do you still feel un-emptied?*
Do you take laxatives?*
- Yes
- No
How long for?*
Do you have flehm or a mucus discharge?*
- Yes
- No
Do you have Sinus?*
- Yes
- No
Do you have Hay Fever?*
- Yes
- No
Do you have Rash?*
- Yes
- No
Where and when?*
Does the rash come and go or is it always present?*
Do you suffer from any of the following? (Please select all relevant options)
- Indigestion
- Gas
- Bloating
- Flatulence
- Constipation
- Diarrhea
- Hemorrhoids
- Cravings
- Bad Breath
- Body Odour
- Sluggish Heavy Feeling
- Poor Appetite
- Excessive Thirst/Hunger
- Sudden Weight Loss/Gain
- Trouble Maintaining/Losing Weight
- Food or Environmental Allergies/Intolerances
Do you crave sweets?*
- Yes
- No
Is your menstrual cycle normal or are you having problems?
- Normal
- Having problems
Please share details about the problems you are having*
How is your dental health*
Do you have finger/toe nail problems?*
Is your mind*
- Good
- Fair
- Poor
- Giving Trouble
- Uncontrolled
- Racing
Is your memory forgetful?*
- Yes
- No
What memory is forgetful*
- Select All
- Short
- Long
Do you have any Depression, Boredom or Irritability?*
Do you have indecision or ongoing stress?*
- Yes
- No
Do you know where it is coming from?*
Do you have headaches or migraines, if so how often?*
Do you have cramps, if so where?*
Do you have cold hands or feet?*
Do you wake up stiff or sore?*
Do you have high or low blood pressure?*
What is your blood pressure?
Please give a brief history of your family’s past and present health problems*
Have you had any serious illnesses or surgeries? Cancer, Tumours, Infectious Diseases, Hospitalisation, Past Surgeries, Surgical Implants or Foreign Objects, Other? Please describe:*
What are your Goals and Desires in the next 6 - 12 months?*
What other Information would you like to share?*
Consent*
I agree to the client consent and waiver policy
Fees and My Service to You
Initial Telephone Consultation: $95 for 40minutes
Normal Follow-up Telephone Consultation: $60 for 30minutes.
If a follow-up consultation takes only 15 minutes, the charge will be $45. If more than 30 minutes is needed, it will be charged at $25 for up to every 15 minutes.
Payment to be made by MasterCard or Visa at the beginning of the Initial Consultation. Follow up Consultations will be charged depending on the time
taken.

Individual Assessment and Planning
Be assured, I will not be following any prescribed protocol for your dietary and lifestyle planning. You will be assessed and planned for as the unique individual you are. You will receive personalised information and resources including
individual food plans, shopping guides, cooking strategies etc to help you Achieve your Goal and Live the Life you have Imagined!

To help you in the best possible way if you are a past or present patient of Peter W. Edwards ND by sending this questionnaire you agree to give me Patricia Edwards permission to access your health record and discuss your case with Peter W. Edwards if more information is needed.

CLIENT CONSENT & WAIVER FORM
Patricia Edwards is Certified in Human Nutrition for Consulting and giving advice and does not claim to hold a medical degree, or practice or teach medicine. She teaches a way of living to promote health by means of diet and lifestyle changes. It is recommended that any change to diet or lifestyle should be made with the advice of a medical practitioner and it is encouraged that you consult your doctor at any time if you have any concerns regarding your health, suffer illness, injury or accident. No changes to medically prescribed drugs are to be made without the
advice of a medical doctor.

To the extent permitted by law, Peter Edwards, Patricia Edwards, Pan Harmony International Pty Ltd, their employees, representatives, agents and consultants
exclude all liability for harm, injury, loss or damage (including indirect, special or consequential harm, injury loss, or damage) arising from the use of, or reliance on, the advice and teaching provided whether or not caused by any negligent act or omission and do not accept responsibility for any injury or harm an individual may come to by using the advice provided.
I, the undersigned, hereby:

1. Acknowledge having received and fully understood the above disclaimer as well as Peter Edwards Pan Harmony clinic policy and procedures and hereby seek advice from Peter Edwards in his role as a Naturopath and lifestyle educator, Patricia Edwards in her role as a Human Nutritional Coach.

2. I understand Peter Edwards and Patricia Edwards are not medical doctors and do hereby declare I will not hold them responsible for any lack or postponement of medical care that the medical profession may deem necessary as it is my choice to seek this method of alternative healthcare.

3. Choose to employ Peter Edwards or Patricia Edwards in his professional capacity to assist me wherever it is possible in their field of training to improving my health and wellbeing.

4. Waive and release any/all claims I may have against Peter Edwards, Patricia Edwards, Pan Harmony International Pty Ltd. arising out of my consultations/ attendances with them (Peter Edwards, Patricia Edwards).

5. Waive any claim arising from any accident, illness or injury arising directly or indirectly from my acceptance of any advice, treatment, or lifestyle recommendation.

6. Indemnify Peter and Patricia Edwards, Pan Harmony International Pty Ltd. and hold these harmless against any claim that either myself, my executors or administrators may have now or in the future against them.

Patricia Edwards Patient Questionaire

Diet

Health