Pre-Consultation Assessment

Use this completely secure and confidential form to give us more information about yourself. We will then contact you to make an appointment and start you on the track towards achieving good health and wellbeing.

Contact Details

Full Name (required)






Your Email (required)

Preferred method of contact

Date of Birth (required)

Occupation (required)

Referral/Medical Fund Information

How did you find Executive Antidote:

Are you a Health Fund Member:

If YES, which fund are you with

Name of Doctor

Doctor's Address

Doctor's Telephone

Current Medical Condition

Main problem for seeking help (required)

How long has the problem been present (required)

What treatments have your received for this problem and when (required)

Medication taken at present

Any medication taken longterm

General Health

Describe your general health

Any other current health problems

List any Allergies

Any supplements taken regularly

Medical History

Describe your past medical history

Past major Illness


Any known liver problems/diseases/illnesses, if so please list

Hospital Admissions and purpose

Extended overseas travel

Family medical history

Diet & Lifestyle

Do you smoke

Do you take the oral contraceptive pill

Typical Daily Diet




Other meals and fluids

Any foods not tolerated well

Describe Appetite

Excercise (Type & Frequency)

Alcohol Intake

Recreational Drugs


Sleep patterns

Respiratory (cough, sinus, shortness of breath)

Excessive thirst

Any hearing or vision problems

Do you find it easy to gain or easy to lose weight

Hair (Dry, normal, oily, thinning)

Nails (Spots, Ridges, Flaking)

Tongue (Coated, Pasty, Coloured)


Bowel habits (regular, loose, constipated)

History of urinary tract infections or thrush

Reproductive - Female

Do you suffer PMS


Do you suffer pain with your cycle


Is your cycle regular (28 days)

Reproductive - Male

Any history of prostate problems


Other reproductive problems


Musculoskeletal problems

General Wellbeing & Work/Life balance

Do you suffer regular colds/flu

Do you suffer regular headaches

Frequency & Severity:

Describe your energy levels (1=poor, 5=excellent)

Daily Life

Average hours worked per week

How many hours do you spend travelling to and from work each week

Describe your work environment

Has your work performance been affected recently, if so how?

How would you rate your work life balance (1=Work, 5=Home)

Does work encroach on your home life, if so how

How do you de-stress from the office

List any major worries you have

Any other comments

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