Electronic Client Vital

Electronic Client Vital - Clinic

Welcome to Your Health Snapshot

We’re honoured you’re here. This form is your space to reflect on what matters to you—and help us understand how to serve you best. Please answer in a way that feels real, not perfect.

First Name

Last Name

Date of Birth

Mobile Number

Current Age

Address

Address Line 1

Address Line 2

City

State

Post Code

Country

Current 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 conditions

Date

How did you hear about our clinic?

Friend

Family Member

Health Practitioner

Radio

Flyer

Webpage

Social Media

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?

Symptom Relief – Feel Better Now - I need support for symptoms like sleep, gut health, energy, hormones, or stress.

Corrective Care – Get to the Root Cause. I want to understand why I feel this way—and use nutrition, lifestyle, and testing to create real change. (Includes symptom relief + a personalised health plan).

AWAKEN – Break the Pattern, Stay on Track. I know what to do—but I keep falling off track, especially when I’m tired, under pressure, or out of routine. I start strong… then sabotage myself with food, alcohol, or numbing habits like scrolling—and I’m tired of feeling that way. I want real support to finally understand and rewire these patterns—so I can stay consistent, feel in control again, and reconnect with the version of myself I know is still in there. (Includes Corrective Care + expert mindset and habit support tailored to your goals).

Longevity & Vitality – Outperform Age. Redefine Your Future. I want more than just “not being sick.” I want to stay sharp, strong, and energised—so I can lead, perform, and thrive at every age. This is for people who see their body as their greatest asset—and want the data, strategy, and support to protect it. (Includes advanced diagnostics, personalised plans, and long-range strategies designed to help you feel incredible—now and into your 80s and 90s).

What’s made it hard to follow through with your health goals in the past?

What would success look or feel like 6 months from now? (Think: how you wake up, what you wear, your energy, mood, or confidence.)

Would you like Victoria to personally reach out and explore whether AWAKEN or Longevity Care might be right for you?

Yes, please reach out

Not at this time

Have you worked with other practitioners, tried other programs, or attempted to make changes on your own before coming to us?

Yes - I’ve seen other practitioners or tried different approaches

No - this is my first time seeking support like this

If yes, please share anything you'd like us to know.If so, what helped—and what didn’t? This helps us avoid repeating things that haven’t worked and build on what has.

Your waistline is more than a number—it's one of the strongest indicators of future health.

Changes in weight—especially around the waist—can reflect shifts in hormones, inflammation, stress load, or metabolic health.

Losing even a few kilos from your waist can improve energy, sleep, hormones, and protect your brain and heart long-term.
For many, it reignites confidence, vitality, and a sense of control that’s been missing for a while.

We'd love to understand if this is part of your health journey. Tick the one that feels most true for you right now.

I’d like to lose 0–5kg – more of a reset or tune-up

I’d like to lose 5–10kg – I know this would shift my energy, confidence, and health

I’d like to lose 10–20kg – This is affecting my quality of life, and I’m ready to change

I’d like to lose 20kg+ – I need a complete physical and behavioural reset

I’m not sure, but I know something’s not right and I want to feel like me again

No—this isn’t part of my current focus

This helps us understand where you're starting—and guide you into the level of care that’s truly going to serve you best.
Many clients who tick 5kg or more benefit most from our AWAKEN or Longevity pathways, where we combine deep clinical insight with behavioural transformation—for results that last.

What tends to get in the way when you're trying to improve your health? Tick any that apply—this helps us support you better, not judge where you're at.

I start strong but lose consistency when life gets busy or stressful

I struggle to prioritise myself—I often put everyone else first

I’ve tried so many things, I don’t know who or what to trust anymore

I worry about spending money on something that might not work

I feel like I know what to do, but I still don’t follow through

I tend to self-sabotage when I’m tired, emotional, or overwhelmed

Honestly… I’m afraid to hope this time will be different

Other - Please specify below.

Let’s Get Specific - Which parts of your daily lifestyle do you feel might be working against your health right now? This helps us understand where small changes could make a big impact.

Nutrition or eating habits

Consistency with movement or exercise

Poor sleep or lack of rest

Struggling to switch off or make space to relax

Feeling disconnected from purpose or creativity

Work/life balance or career-related stress

Coping behaviours that aren’t serving me (e.g. alcohol, stress-driven eating, screen time)

Unhelpful thinking patterns or habits that keep me stuck

Other - Please specify below

Investment in Your Health

We know that caring for your health is both a personal and financial commitment—and everyone’s in a different season of life. That’s why we offer a range of care options: from short-term relief to deep behavioural and metabolic transformation.

This section helps us understand how to support you best—without pressure, and with full respect for your goals and resources.

Which of the following feels most true for you right now? Tick the one that best fits where you're at right now.

I’m ready to prioritise my health and open to exploring high-level care that includes deep clinical and mindset support

I’m motivated to make change, but I need something more flexible or suited to a smaller budget right now

I want support, but finances are currently a major constraint—and I’d appreciate options that meet me where I’m at

Thank you for taking the time to reflect and share with us.

We’re truly honoured to be part of your health journey—and look forward to helping you feel strong, clear, and supported in the days ahead.