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First name

Last name

Email

Phone

Birthday

Day

Month

Year

Emergency Contact

Emergency Contact Number

Gender

Height (cm)

Current Weight (kg)

What is your main health or nutritional goal?

Do you have a target weight or specific outcome in mind?

Please provide details of any conditions selected above

Have you had any recent surgeries, hospitalisations or significant health concerns?

Yes

No

If yes please provide details

Are you currently pregnant or breastfeeding?

Yes

No

N/A

Are you currently taking any prescription or non-prescription medications?

Yes

No

If yes please list the medication, dose (if known) and reason for taking it.

Do you currently take any vitamins, minerals, herbal products or nutritional supplements?

Yes

No

If yes please list your current supplements and approximate doses.

Do you have any known food allergies or intolerances?

Yes

No

If yes please list them and describe the reaction where relevant

Are there any foods you cannot or do not want to eat?

Currently how many meals do you typically eat per day?

How often do you eat takeaway or restaurant meals?

Please describe what you typically eat in a normal day

How physically active are you?

How many days a week do you exercise?

What types of exercise do you normally perform?

Average sleep per night?

How would you describe your current stress level?

Do you smoke or vape?

Have you had blood tests performed within the last 12 months?

Yes

No

Unsure

Would you like to upload recent pathology results for review? (optional not mandatory)

I confirm that the information I have provided is accurate and complete to the best of my knowledge.

I understand that nutrition and wellness services are not a substitute for medical diagnosis, emergency care or treatment from my doctor or other qualified healthcare professional.

I understand that I should inform iHealth Wellness of any significant changes to my health, medications or medical conditions.

I consent to iHealth Wellness collecting and using the health information I provide for the purpose of delivering the requested service, in accordance with its privacy policy.

Privacy Policy & Health Disclaimer Consent

I confirm that I have read and understood the iHealth Wellness Privacy Policy & Health Disclaimer. I consent to iHealth Wellness collecting and handling the personal and sensitive health information I voluntarily provide for the purpose of delivering the services I have requested.

I understand that iHealth Wellness provides nutrition, lifestyle and general wellness information and does not provide medical diagnosis, prescribe medication, or replace advice

POLICY & DISCLAMER | Ihealth Nutrition https://www.ihealthwellness.com.au/policy-disclamer

I confirm that I have read and agree to the iHealth Wellness Privacy Policy & Health Disclaimer, and I consent to the collection and handling of my personal and sensitive health information for the purpose of providing the services I have requested.

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Ihealth Wellness Intake Form