Electronic Client Vital Electronic Client Vital - Clinic First NameLast NameDate of BirthPhone Number Home Phone Number Work Mobile Number Current Age EmailAddressAddress Line 1Address Line 2CityStatePost CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweCurrent Medications Terms and conditions: We greatly respect your time as our client and take your health very seriously. We kindly ask that if you need to cancel your appointment you do so no less than 48 hours prior, so that we may help somebody else reach their health goals. A $99 cancellation fee will apply for cancellations within 24hrs of your appointment. All consultation fees must be paid at the time of your appointment. By attending your appointment, you are agreeing to this condition.Signature Sign Here Please sign here to confirm that you have understood these conditionsDate Save ProgressPreviousNextHow did you hear about our clinic? Friend Family Member Health Practitioner Newspaper Television Radio Flyer Brochure Webpage Magazine Facebook Other If you were referred to the clinic by a friend/family member/or another health practitioner or service provider, please provide their name(s) so that we may thank them:What level of healthcare are you interested in? Symptomatic Care - Support and relief from symptoms Corrective care - Provides symptomatic relief and looks into the causes through diet and lifestyle. Corrective Care also looks deeply into your health issues and creates powerful life changes. AWAKEN – Do you struggle with “I know what to do but I can’t seem to follow it”? Any emotional eating, stress eating, comfort eating, binge eating, drinking and self-sabotage Anti-Aging Care – Have you ever wondered if your genes will impact your health in the long term? Gene testing reveals your unique genetic profile and is the future of nutritional medicine in disease prevention. Here we can individualise treatment to either switch on or off your genes, reducing your overall risk of diseases, such as heart disease, cancer, Alzheimer’s etc. This is a must for anyone who wishes to optimise health longevityHow long do you think it will take you to achieve your health potential?Why is your health important to you?Do you use Tobacco Recreational drugs Coffee Alcohol Sweets Chocolate Other If you have answered yes to any of the above, do you believe that these habits can/will compromise your health and vitality? Yes No What current behavioural/lifestyle habits, do you believe need to change to benefit your health? Diet Exercise Rest Relaxation Occupation Creative Expression Addictive Behaviours Emotional Responses Reflect on your priorities and list the highest 3 in your life and present?Do you believe your present lifestyle and state of health is affecting any of the following: Income Vitality Quality of Life Relationships Future Health Emotions CareerWhat level of resources are you prepared to commit to your health and wellbeing? Time Low Medium High Energy Low Medium High Finance Low Medium High What do you think could stop you from achieving your health potential? Time constraints Commitments Financial resources Emotional support Lack of interest Effective Other In order to achieve your true health potential, how much education/training/motivation do you feel you need? Rate 1-10, 1=lowest, 10=highest 1 2 3 4 4 6 7 8 9 10 Previous Submit Form
