Dr Diary Form – World of Wellness

Client details:

Name:

Client ID: 0

Notes
Prescription
Suitability
Health Information Form
History
Informed Consent

Attach files

Prescription Form

Doctor's Name*

Doctor's Qualifications*

Provider Number*

Name of Practice*

Telephone Number*

Address*

Post Code*

State*

Country*

Patient's Name*

Birth Date*

Patient's mobile number*

Patient's Address*

Postal Code*

State*

Country*

Medicare number

PBS

RPBD

Prescription:

API for Skinny World Diet Program

Prescription Helper

Sex

female

male

other

Menstruating

Yes

26 Day Program

30 Day Program

43 Day Program

Item

Unit

Repeat

Instructions

Item	Qt	Repeat	Instructions

Prescription Form

Title

First Name

Last Name

Sex

female male other

Date of Birth

Country

Email*

Body mass index

Measurement system

Metric Imperial

Weight (kg)

Height (cm)

BMI

Health History

Asthma

Yes No

Select one *

Medication

History of Cancer

Yes No

Select one *

Medication

Years in remission

Primary diagnosis

Metastasis

Depression

Yes No

Select one *

Medication

Diabetes

Yes No

Select one *

Treatment

Medication

Epilepsy

Yes No

Select one *

Frequency

Medication

History of Gout

Yes No

Headaches

Yes No

Select one *

Frequency

Medication

Severity of Pain

1 2 3 4 5 6 7 8 9 10

Heart Disease

Yes No

Please select *

Medication

Renal Dysfunction

Yes No

Please select *

Menstruating

Yes No

When was the first day of your last period

Not Applicable

Problems with your period

Yes No

Describe

History of Polycystic Ovaries

Yes No

History of Ovarian Hyperstimulation Syndrome

Yes No

Are you currently Pregnant

Yes

Are you Breast Feeding

Yes

Have you entered or are you past Menopause

Yes

Do you take Hormone Replacement Therapy

Yes

Have you had any children

Yes

Did you experience morning sickness during pregnancy

Yes

Please select *

What is your normal diet

Other relevant History

Other medication

I understand that the information I record herein is used by Skinny World to assess my suitability for the Skinny World Diet Program. By signing this form I declare that I have divulged all relevant medical history and that all the information I have submitted is true and correct.

I agree to received promotional material from Skinny World and World of Wellness.

First Name

Last Name

Sex

female male other

Date of Birth

Mobile

Your Time zone

Email*

Corporate or customer loyalty program code

Blood type

A AB B O Don't know

Body mass index

Measurement system

Metric Imperial

Weight (kg)

Height (cm)

BMI

Would you like to lose weight?

Yes No

Have you tried to lose weight before?

Yes No

What diets have you tried?

Health Status

Do you have OR do you have a family history of the following:

Addictions

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Allergies

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Autoimmune – e.g. arthritis,

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Bowel disorders

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Cancer

Yes No Family

What type:

Metastasis

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Surgery: approximate if not sure

Surgery date

Radiation: approximate if not sure

Start

End

Chemotherapy: approximate if not sure

Start

End

Cardiovascular disease, hypertension, stroke

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Communicable disease – e.g. HIV, STDs

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Diabetes

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Digestive problems – e.g. GERD, gall bladder, pancreas, ulcers

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Disability

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Endocrine disorders – e.g. hypothyroidism, adrenal gland disorders

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Infectious diseases – e.g. Ross River Virus, Lyme Disease etc.

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Kidney Disease

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Liver Disease

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Lung disorders – e.g. asthma, cystic fibrosis

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Mental Illness – e.g. anxiety disorder, depression, PSTD, bipolar etc

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Neurological disorders

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Overweight

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Reproductive conditions

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Other

Yes No Family

What

Treatment

Family

Mother

Father

Sibling

Grandparent

Aunt/Uncle

Medication and Supplements

Do you currently take any medication – if so, please list name of drugs, dose and frequency

Name of Medication

Dose

Frequency

Do you take any supplements – if so list name, dose and frequency:

Name of Supplement

Dose

Frequency

Do you take cannabinoids for recreation or medical treatment – if so, list name and frequency:

Name of Drug

Dose

Frequency

Surgical history

Procedure

Year

Lifestyle

Do you smoke?

No Yes

Number per day

When did you start

Have you ever smoked?

No Yes

Number per day

When did you start

When did you stop

Do you currently exercise?

No Yes

Type

No. days per week

Duration

What is your normal diet

Non-Vegetarian Pescatarian Vegetarian Vegan Gluten Free Paleo Low Carb Other

Pathology Reports

Attach your reports here

Date/Time	Who	Detail
2018-07-24 11:20:00		Booking Reference No: 24 booking status: CANCELLED Long Consultation
2018-07-31 17:10:00		Booking Reference No: 23 booking status: CONFIRMED Standard Consultation
2018-07-19 14:00:00		Booking Reference No: 22 booking status: CANCELLED Standard Consultation
2018-07-25 11:00:00		Booking Reference No: 21 booking status: COMPLETED Standard Consultation
2018-07-17 14:30:00		Booking Reference No: 20 booking status: CANCELLED Standard Consultation
2018-07-18 13:20:00		Booking Reference No: 19 booking status: MISSED Standard Consultation

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