Opus Healthcare New Patient Form

Name*Email*Phone*Age*Date of Birth*

Address*Suburb*Postcode*Sex*

Spouse/Next of Kin*Referred By

Spouse/Next of Kin

List of any prior diagnosis*What makes your condition worse?*

Have you missed/lost any work due to this condition?*What makes your condition better?*

Have you had X-rays?*

YesNo

Latest blood test (date)*Results (if known)

Any other tests? (urine, stool, saliva)*

YesNo

Did you suffer any trauma during birth?*What are your goals that you would like Dr Adrian Clegg help you achieve?*

Please list your PHYSICAL STRESSORS:
(Eg: prolonged sitting, gym work, running etc)

Please list your EMOTIONAL/MENTAL STRESSORS:
(Eg: work stress, family stress, financial pressure)

How many hours sleep on average per night do you get?*Do you smoke?*

YesNo

Do you have food allergies, sensitivities or restrictions?*Do you drink alcohol?*

YesNo

I experience problems falling asleep

I experience problems staying asleep

I frequently experience a second wind (high energy) late at night

I have energy highs & lows throughout the day

I feel tired all the time

I need caffeine (coffee, tea, cola, etc) to get going in the morning

I usually go to bed after 10pm

I frequently get fewer than 8 hours of sleep per night

I am easily fatigued

Things I used to enjoy seem like a chore lately

My sex drive is lower than it used to be

I suffer from depression, or have recently been experiencing feelings of depression such as sadness or loss of motivation

If I skip meals I feel low energy or foggy & disorientated

My ability to handle stress has decreased

I find that I am easily irritated or upset

I have had one or more stressful major life events (i.e.: divorce, death of a loved one, job loss, new baby, new job)

I tend to overwork with little time for play or relaxation for extended periods of time

I crave sweets

I frequently skip meals or eat sporadically

I am experiencing increased physical complaints such as muscle aches, headaches, or more frequent illnesses.

How often do you exercise?*If you do not currently exercise, what types of exercise have you enjoyed doing in the past?

What is your regimen?*
Surgeries:

Date of last menstrual period:

Do you have any reason to believe you are pregnant?

YesNoMaybe

Book appointment

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NEW PATIENT HISTORY FORM

Returning Patient?

Dr. Adrian Clegg

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