Instructions for Completing This Form
This form is an editable document.
You can type your text into the grey text fields which appear as follows:
……………………………
Please be sure to save the form using your own name as the new file name so that
we can easily identify the document as containing your personal data.
When you have finished filling out the document, please email it back to us at
admin@lotusholisticmedicine.com.au
Please return the completed forms to the clinic at least one week
prior to your initial intake consultation.
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
1
Dear Client,
Congratulations on making an important step towards the attainment of long-term vibrant health. As you probably
know, the emphasis of my practice is on seeking the underlying causes of poor health rather than focusing on
symptom relief.
This means going deeply into your diet, lifestyle and daily routine and assisting you to find the individualised health
regime which will help to “switch off” the program which is driving many of your current health challenges.
This approach means that you will be able to take your health into your own hands, and learn how to stay well, track
your progress and learn better to work with your own individual make-up.
In order to achieve the best possible outcome, we ask that you please have the following information
completed in full and returned to the clinic at least one week prior to your initial consultation:
Client Registration Form
Health History Questionnaire
Signed Medical Consent Form
Completed Charts and Checklists
Signed Fees and Charges Form
Health Goals & Readiness Assessment
Copies of any relevant recent medical records from
your main treating practitioner
Copies of any relevant pathology results you may
have had over the last 2-3 years (see below)
Please indicate by checking the box below which labs you have had any relevant pathology with so that we
can access these reports on your behalf before your initial consultation:
Queensland Medical Laboratories (QML)
Sullivan & Nicolaides (S&N)
Healthscope Pathology:
Coastal Pathology
Other:
IMPORTANT: The information requested above is required to be provided at least seven working days prior to your
intake consultation. Provision of this information is important as it will familiarise Dr Gupta with your health history and
issues to be addressed before you arrive, thereby making the most of your consultation time.
PLEASE DO NOT TAKE ANY NUTRITIONAL SUPPLEMENTS FOR TWO MEALS BEFORE YOUR INITIAL CONSULTATION,
ENSURE YOUR FINGER NAILS ARE CUT REASONABLY SHORT AND WITHOUT NAIL POLISH
I look forward to being of service.
In good health,
Dr Sandeep Gupta
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
2
Client Registration Form
Personal Information
Title:
Mr
Mrs
Ms
Miss
Dr
First Name:
Middle Name:
Date of Birth: Day -
Month -
Surname:
Year -
Contact Details
Postal Address:
Suburb:
State:
Postcode:
Home Phone:
Mobile Phone:
Work Phone:
Email:
Medicare Card Details
10 Digits:
Expiry Date: Month -
Year -
Medicare Reference Number:
(number to the left of your own name on the card)
Communication Preferences
Phone
Email
Would you like to receive our e-newsletter electronically?
Would you like to receive appointment reminders via SMS?
Yes
Yes
No
No
Emergency Contact Details
Full Name:
Contact Phone Number:
Relationship to You:
Consent
I consent to the use and disclosure of my personal health information by Lotus Holistic Medicine to other practitioners directly or
indirectly involved in my medical treatment and care.
SIGN HERE
*Signature:
Date: Day -
Month -
Year -
*To sign this form electronically please place a backward slash \ at the beginning
and end of your name as follows: \client name\
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
3
Medical Consent Form
I, (please insert your full name),
of, (please insert your address)
understand that:

I am seeking to consult Dr Sandeep Gupta in his capacity as a medical practitioner with a special interest in nutritional and
environmental medicine.

Dr Gupta’s approach involves a longer than standard consultation time and a more holistic approach to patient treatment
and care – primarily involving diet, supplementation, exercise, and lifestyle change and stress management.

Dr Gupta charges a private fee for his consultations, which, in the majority of cases attracts a Medicare rebate. In most
cases he does not bulk bill. This is due to the model of care we provide not fitting with bulk billing.

The majority of diagnostic tests ordered by Dr Gupta do attract a Medicare rebate; however specific functional pathology
tests may not attract a rebate. The costs of these tests will be discussed with me by Dr Gupta at the time of ordering.

Dr Gupta may offer some recommended products for purchase from his clinic directly via Evolutionary Health Solutions, a
related business. This is provided as a service and there is no obligation to purchase any products from our clinic or any
businesses we recommend. Supplements may be purchased from any retailer of choice.

Some of the treatment suggestions (e.g. nutritional or digestive supplements) offered by Dr Gupta are considered to be
outside the parameters of conventional medicine in Australia. These treatments fall under the category of complementary
or alternative medicine.

These interventions are in the majority of cases supported by research evidence, and are only prescribed with utmost care
and within Dr Gupta’s area of training, knowledge and expertise as in integrative medical doctor.
I am attending Dr Gupta’s clinic of my own free will and consent and exercise my right to discuss and choose any suitable
treatment options made available to me.
SIGN HERE
*Signature:
Date: Day -
Month -
Year -
*To sign this form electronically please place a backward slash \ at the beginning
and end of your name as follows: \client name\
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
4
Fees and Charges Form – Part 1
Fee Schedule
Dr Gupta charges a private fee for his consultations, which in the majority of cases attracts a Medicare rebate.
SUNSHINE COAST CLINIC
 $540.00 for a 1 hour 30 min initial consultation
 $180.00 for a subsequent consultation of 30 mins
 $70.00 minimum consultation charge
 Pro-rata $60.00 per 10 minutes
SYDNEY CLINIC
 $810.00 for a 1 hour 30 min initial consultation
 $270.00 for a subsequent consultation of 30 mins
 $70.00 minimum consultation charge
 Pro-rata $90.00 per 10 minutes
Payment of Fees
All fees are payable at the time of consultation. Payments can be made via cash, EFTPOS and credit card.
Concession Rates
Due to the longer appointment duration Dr Gupta provides concession rates are not available.
Medicare Rebates
At the Sunshine Coast clinic we are able to process your Medicare rebate at the time of consultation. To facilitate this, please bring
your Medicare Card and a key card that is attached to a savings or cheque account. Currently, Medicare rebates are unable to be
provided at the Sydney clinic - you will be issued with a tax receipt which you will need to take to Medicare to claim your rebate.
Bulk Billing Policy
Lotus Holistic Medicine is not a bulk billing practice. The only exception to this is annual or three monthly care plans which may be
bulk billed when Medicare eligibility criteria are met.
Cancellation Policy – New Clients
A deposit of $150.00 is required to secure your new patient intake consultation which is payable at the time of booking your
consultation. This deposit can be made over the phone by credit card or directly to the following account:
ACCT NAME: Radiant Life
BSB: 064 420
ACCT NO: 1079 6709
Please be sure to use your own name as the payment identification reference.
Please note that 48 hours notice is required if you wish to cancel or reschedule your initial
intake consultation.
The deposit amount of $150.00 is non-refundable if less than the specified 48 working hours notice is provided and we are unable
to fill your consultation time from our waiting list. If you wish to cancel or reschedule your appointment please do not leave a
message on the answering machine or send an email over the weekend – cancellations and rescheduling must be completed
during working hours Monday – Friday. Please ensure that you speak with client support staff personally or receive an email
confirmation to verify that your request to cancel or reschedule has been received and processed.
Contact details for cancellations and rescheduling:
Phone: (07) 5457 3483 or Email: admin@lotusholisticmedicine.com.au
We do understand that there are rare occasions when it is not possible to give 48 hours notice to cancel or reschedule your
appointment. In these instances, if we are able to fill your appointment from our waiting list, your deposit may be refunded or
transferred to your rescheduled consultation time, however a refund is not guaranteed.
If you do not attend your new client intake appointment and do not provide advance notice of your inability to attend a no-show fee
of $150.00 is payable.
Please check the box below:
I have read, understand and agree to the new client cancellation policy as outlined above
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
5
Fees and Charges Form – Part 2
Cancellation Policy – Existing Clients
If you do not attend your appointment and do not provide advance notice of your inability to attend a no-show fee of $50.00 is
payable.
Please check the box below:
I have read, understand and agree to the existing client cancellation policy as outlined above
Appointment Reminders
An SMS appointment reminder service is available – please ensure that you register for this service by checking YES on the Client
Registration Form found on page 3 if you would like to be reminded of your consultation in advance. Lotus Holistic Medicine does
not take responsibility for SMS reminders not received. It remains the clients’ responsibility to keep track of their appointments and
to update their mobile phone number with our reception staff if their contact details change. Please note that the SMS reminder
service is a NO REPLY service – which means that you must call us or send an email if you are unable to attend your appointment
or need to reschedule.
Email Policy
Generally we are available by email for simple clarifications of aspects of the treatment protocol such as a dosage of a medication
or supplement or problem obtaining a particular product or supplement.
We also request clients to notify us of any significant new symptoms that occur while on the holistic medicine program.
When a discussion needs to take place to clarify the exact nature of symptoms and to devise a plan, Dr Gupta may ask for a
physical or telephone consultation, as generally it is considered good medical practice to assess a patient thoroughly before
suggesting a course of action. Generally this will attract a short consultation fee.
For extensive questions, such as how to tailor your diet exactly to fit the holistic medicine program or significant changes to your
program which are requested, Dr Gupta will generally request a phone or email consultation. An extensive email consultation fee is
generally $120 which includes responding in depth to several questions generally taking around 20 minutes of Dr Gupta's time.
Results Policy
Generally results will be forwarded from imaging or pathology companies directly to Dr Gupta for review. In general our policy is to
contact clients with results only if immediate action is required on the basis of this result, e.g. change in the medication or
supplement program, or hospitalisation. It is not our routine practice to send all results to patients. Our preferred practice is for you
to request any results you require during a consultation with Dr Gupta. However if not possible, results may be requested by email
after they are available and they will be forwarded onto you.
Please check the box below:
I have read and understand the fees and charges as outlined in this document
SIGN HERE
*Signature:
Date: Day -
Month -
Year -
*To sign this form electronically please place a backward slash \ at the beginning
and end of your name as follows: \client name\
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
6
Support on the Health Journey
Clinic Opening Hours
Sunshine Coast: Tuesday – Thursday from 9.00am – 5.00pm.
Sydney: Once a Fortnight on Friday from 9.00am – 5.00pm.
How to Contact Us
We are very happy to receive any questions, consult bookings and advice of cancellations via email. You can also phone us and if
we are busy on another call or the clinic is unattended, please leave a message and we will return your call. We do intermittently
monitor emails on weekends, so if you need a response outside of normal clinic hours this is the most efficient way to contact us.
Woombye Clinic: 56 Plantation Rise Drive, Woombye QLD 4559
Sydney Clinic: Fayworth House, Suite 605, 6th Floor, 379 - 383 Pitt Street, Sydney NSW 2000
Postal Address: PO BOX 1113 Buderim QLD 4556
Phone: (07) 5457 3483
Email: admin@lotusholisticmedicine.com.au
When to Contact Us
Please contact us if you are having any problems related to implementing your treatment program including the diet and any
lifestyle changes. Please also contact us if you are unsure of any of your dosages, if you experience any significant deterioration in
your condition, or if you have any adverse reaction to any supplement or medication that Dr Gupta has prescribed.
Communication Response Times
We aim to respond to all messages within 24 - 48 hours of receipt during regular clinic hours, however please be aware that
messages and requests received are triaged in order of urgency so occasionally longer response times may occur.
Filling Out Forms
If you require a form filled out to receive a benefit or a permit this usually needs to be completed within the context of a consultation
– please mention at the time of booking your appointment that you require forms to be completed.
Medical Emergency
As the clinic opening hours are limited to Tuesday – Thursday from 9.00am – 5.00pm, please contact your nearest emergency
medical department or phone an ambulance on 000 if a medical emergency should arise.
Maintaining a Regular GP
Due to the emphasis on nutritional and environmental medicine, Dr Gupta suggests maintaining a relationship with a regular GP for
routine matters such as immunisations, surgical screening tests and any simple matters that you may prefer to have bulk billed.
Obtaining Medical Results & Reports
We are more than happy to provide email copies of your test results to you when these are required, however we do not routinely
supply ‘normal’ test results to patients. If you need your results to be printed out and posted in hard copy this may attract a small
fee, depending on the quantity of printing and postage required.
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
7
Health History Questionnaire
The information on this form is to help Dr Gupta to assess and treat you effectively. It is important that you take the time to fill this
out completely to ensure the best outcome can be achieved. If you are unsure about any information you will be able to discuss it at
the initial consultation.
MAIN CONCERNS
Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each
symptom has been present.
PROBLEM
e.g. headache
ONSET
June 2007
FREQUENCY
4 times per week
SEVERITY
mild/moderate/severe
1.
2.
3.
4.
5.
6.
Q. What diagnoses or explanations have been given to you?
Q. When was the last time you felt well?
Q. Did something trigger your change in health?
Q. What makes you feel worse?
Q. What makes you feel better?
Please list any other practitioners you have seen for the listed health conditions:
1.
4.
2.
5.
3.
6.
Please check the box for any complementary treatments you have tried for your condition/s:
None
Chiropractic
Acupuncture
Iridology
Colonics
Massage
Rolfing
Reiki
Homeopathy
Biofeedback
Yoga
Hypnosis
Ayurveda
Light Therapy
Meditation
Environmental Medicine
Nutritional Therapy
Biological Dentistry
IV Chelation Therapy
Naturopathy
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
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Past Illnesses
Please place the date corresponding to when you experienced or first started to suffer from any of the following
conditions in the past and add any comments as required:
ILLNESS
Chicken Pox
German Measles
Measles
Mononucleosis
Mumps
Whooping Cough
Anaemia
Arthritis
Asthma
Bronchitis
Cancer
Chronic Fatigue
Syndrome
Crohn’s Disease or
Ulcerative Colitis
Diabetes
Emphysema
Epilepsy or
Convulsions
Gallstones
Gout
Heart Attack/Angina
Heart Failure
Hepatitis
High Blood Pressure
Irritable Bowel
Kidney Stones
Glandular Fever
Pneumonia
Rheumatic Fever
Sinusitis
Sleep Apnoea
Stroke
Other: (describe)
Other: (describe)
DATE
DATE
X
X
X
X
X
X
DATE
X
X
X
X
X
X
COMMENTS
Past Injuries
Please place the date corresponding to when you suffered from any of the following injuries in the past and add any
comments as required:
INJURY
DATE
DATE
DATE
COMMENTS
Head Injury
Neck Injury
Back Injury
Fracture
Other: (describe)
Other: (describe)
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
9
Past Diagnostic Testing
Please place the date corresponding to when you had any of the following diagnostic tests in the past and add any
comments as required:
TEST
DATE
DATE
DATE
COMMENTS
Chest X-Ray
Mammogram
ECG
Sigmoidoscopy
Colonoscopy
Upper GI Series
Barium Enema
CT Abdomen
CT Brain
CT Spine
Liver Scan
Bone Scan
Neck X-Ray
Back X-Ray
MRI
Bone Density Test
Carotid Artery USS
Blood Tests
Allergy Testing
Other: (describe)
Other: (describe)
Medication Log
Please list all medications you are currently taking – both prescription and non-prescription:
MEDICATION NAME
DATE STARTED
DATE STOPPED
DOSAGE
# PER DAY
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
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Supplement Log
Please list all vitamins, minerals and any other nutritional supplements you are currently taking:
SUPPLEMENT NAME/BRAND
DATE STARTED
DOSE
# PER DAY
REASON FOR USE
Q. Have your medications or supplements ever caused you adverse side effects or problems?
YES
NO
If YES, please describe:
Family & Social History
Q. Does anyone in your family or a near relative have any of the following? Please indicate whether this is on the Maternal
or Paternal side of the family:
CONDITION
YES
NO
MATERNAL
PATERNAL
Diabetes
Hypertension
Heart Disease
Stroke
Colon Cancer
Depression
Breast Cancer
Other: (please list)
__
Other: (please list)
__
Q. Is your mother alive?
YES
NO If NO, age at death?
Cause of death?
Q. Is your father alive?
YES
NO If NO, age at death?
Cause of death?
Q. What is your current occupation?
Q. Have you ever been significantly exposed to any of the following through your occupation?
Dust
Radiation
Asbestos
Animals
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
11
Rest & Relaxation
Q. Do you take time to rest and relax each day?
YES
NO
Q. What is your present rest and relaxation pattern?
Please describe:
Q. Does this provide enough rest and relaxation for you?
YES
NO
Q. Would you say that your life one of excess or moderation?
Please explain:
Q. Do you moderate use of your time so that you often find yourself… Please check all that apply:
Relaxed and Refreshed
Hurried
Exhausted
Irritable
Poised and Focused
Scattered and Unfocused
Bored
Desperate
Nutrition
Q. Have you made any changes in your eating habits because of your health?
YES
NO
Q. Do you currently follow a special diet or nutritional program?
YES
NO
Q. What kind of diet do you eat? Please check all that apply:
Mixed Food Diet (animal and vegetable foods)
Low Starch/Carbohydrate
High Protein Diet
The Blood Type Diet
Vegetarian
Metabolic Typing Diet
Vegan
The Zone Diet
Raw Foods
Total Calorie Restriction
Gluten Restriction
Diabetic
Low Sodium
Sports Performance
Fat Restriction
Special Weight Loss Diet
Please check any specific food restrictions that you have:
Dairy
Soy
Eggs
Wheat
Corn
Gluten
Others: (please list)
Q. Is there anything else special about your diet?
Describe:
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
12
Lifestyle
Q. Have you ever smoked?
YES
NO
Q. If yes, how long did you smoke?
Q. Are you currently a smoker?
YES
NO
In an average week, please details how much and what type of the following you partake in:
ITEM
HOW MUCH
CIGARETTES
cigarettes per day
ALCOHOL
drinks per week
RECREATIONAL DRUGS
occasions per week
EXERCISE
occasions per week
RELAXATION
times per week
WHAT TYPE
Q. Do you have a regular spiritual or religious practice?
YES
NO
If it feels appropriate for you, please explain a little more about your spiritual practice:
How often do you…?
Walk barefoot on the earth:
Get outside and in to nature:
Get direct sunlight for at least 30 minutes per day:
Chew your food until it is like liquid in your mouth:
Express gratitude for all that you have:
Forgive significant people in your life:
Take time out to relax and turn the stress system off:
Go deeply into the silence within your own self:
Work/Home Environment
Q. Is your home environment emotionally and spiritually uplifting?
YES
NO
Comments:
Q. Does your work environment generally provide a pleasant experience that you enjoy?
YES
NO
Comments:
Q. Have you ever been directly exposed to chemicals, or heavy metals such as mercury, lead, cadmium or pesticides?
YES
NO
Comments:
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
13
Chart 1: Basal Body Temperature (optional)
On waking, before getting up, place the thermometer under your armpit. It is important to make as little movement as possible.
Lying and resting with your eyes closed is best. Wait until the thermometer beeps four times (or wait 90 seconds), then remove it
and record the temperature in the chart. Record the temperature for at least three mornings - preferably at the same time of day
and always before getting out of bed.
Women with a menstrual cycle must perform the test on the days between the second and ninth days after starting the period.
Date:
37.3
37.2
37.1
37.0
36.9
36.8
36.7
36.6
36.5
36.4
36.3
36.2
36.1
36.0
35.9
35.8
35.7
35.6
35.5
35.4
35.3
35.2
35.1
35.0
34.9
34.8
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
14
Chart 2: Three Day Dietary History
Please complete the following three day dietary history of your usual food intake – include everything that you eat over the three
days before a meal, at a meal and any snacks. Also include all the drinks you consume including the amount of water. Please also
note the approximate quantities that you consume and anything that you add to your food, such as sugar.
Example
Day 1
Day 2
Day 3
1 glass water
1 cup of coffee with 1 tsp of
sugar and milk
1 wholemeal cheese and
tomato sandwich
1 muesli bar
1 bowl of just right cereal with
low fat milk and 1 tsp honey
1 medium banana
1 glass orange juice
1 bowl of minestrone soup
1 white bread roll with butter
1 glass red wine
1 glass water
6 squares of chocolate
On Rising
Breakfast
Morning Tea
Lunch
Afternoon Tea
Dinner
Pre-Bed
Other
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
15
Chart 3: Slow Oxidiser Profile
YES
1.
Do you eat to live?
2.
Can you go a long time without eating?
3.
If you skip meals, is it easy for you to maintain energy and a sense of well being?
4.
Are you generally not concerned much with eating?
5.
Do you have a minimal appetite for lunch?
6.
Do you have a minimal appetite for dinner?
7.
Do you love sweets and need something sweet with a meal to feel satisfied?
8.
Does eating before bedtime worsen sleep?
9.
Does eating fatty foods lmake you feel lethargic?
10.
Does eating a high protein meal drop your energy afterwards?
11.
Does eating sweets or fruits restore lasting energy and give you a sense of well being?
12.
Does apple or orange juice alone energize and satisfy you for a long time?
13.
Do high carbohydrate, low protein, low fat vegetarian meals (salads, fruits) make you
NO
generally feel well satisfied and energised?
14.
If you could eat anything you wanted (what you like) at a buffet, would you sample all the
salads and leave room for the desserts?
15..
Do you handle juice or water fasts well?
16.
If you feel low energy, does eating sweets or fruits restore lasting energy?
17.
Are you particularly fond of potatoes?
18.
Do you have a sense of sustained well being after eating sweet foods?
19.
Do foods often taste too salty?
20.
Does eating red meat seem to decrease your energy and sense of well-being?
21.
If you are a vegetarian, can you recall whether eating eat red meat in the past used to
decrease your energy and sense of well-being?
22.
Do you get sleepy or lethargic eating a high protein, high fat meal?
23.
Do you particularly care for sour foods such as lemons?
24.
Do you rarely want snacks?
25.
Is it easy for you to go more than 4 hours without food?
26.
Is a low protein, high carbohydrate diet easy and natural for you?
27.
Do you feel good and energetically sustained after eating grains such as rice or bread?
28.
Has your general health and well being improved since becoming vegetarian or avoiding
high protein foods?
29.
Did you grow up having any aversions to eating animal protein?
30.
Did you grow up having any aversions to eating fatty foods?
31.
Does eating a diet based primarily fruits and vegetables give you a sense of well-being?
TOTAL
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
16
Chart 4: Fast Oxidiser Profile
YES
1.
NO
Do you have a strong appetite for breakfast?
2.
Do you have a strong appetite for lunch?
3.
Do you have a strong appetite for dinner?
4.
Do you need to snack frequently?
5.
Does a high carbohydrate diet with fruits/veggies/sweets make you feel worse or not satisfy you?
6.
Do you feel satisfied after a high protein meal like tofu, beans, spirulina, nuts, seeds, or chlorella?
7.
Do you feel better after a high protein meal?
8.
Do you like to eat potatoes?
9.
Do you crave animal protein foods?
10.
Does a high protein meal give you a sense of increased energy and well being?
11.
Does going 4 hours without food make you feel jittery or weak?
12.
Do you need to snack often to feel okay?
13.
Do you live to eat?
14.
Do you prefer fatty foods over sweets?
15..
Does eating sweets throw you out of balance?
16.
Does eating sweets deplete your energy within an hour?
17.
Does eating before sleep help you sleep?
18.
Does eating before sleep help you to sleep through the night?
19.
Does having orange or apple juice alone make you feel light headed or hungry?
20.
Does eating a high protein or fatty meal seems to restore your energy and a feeling of well-being?
21.
If you are vegetarian, can you remember if eating red meats used to give you energy?
22.
Does eating fruit, pastries or candy make you feel worse?
23.
Is it hard for you to fast on juice or water?
24.
Do you really not care for sweet deserts, but may enjoy something fatty or salty?
25.
Do you feel worse after eating grains?
26.
Do you like sour foods?
27.
Do sweet foods often seem too sweet to you?
28.
Do you get a quick lift, and then suddenly a drop of energy when you eat sweet foods?
29.
If you skip meals, does it cause you to feel weak, jittery, low in energy and imbalanced?
30.
Do you love or crave salty foods?
TOTAL
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
17
Chart 5: Injuries, Scars & Operations
Please check the box or describe where appropriate:
Q. Do you have any implants? e.g. breast, metal plates or pins, dental
YES
NO
Please describe:
Q. Have you sustained any major injuries or had any major accidents?
YES
NO
Please describe:
Q. Do you have any piercings or tattoos?
YES
NO
Please describe:
Q. Do you have any dental amalgams? i.e. silver fillings
YES
NO
If yes, how many amalgams do you have?
Q. Have you had any dental root canals?
YES
NO
If yes, how many root canals do you have?
Please place the date corresponding to when you had any of the following operations in the past and add any comments
as required:
OPERATION
DATE
DATE
X
X
Appendectomy
X
X
Gallbladder Removed
X
X
Tonsillectomy
DATE
COMMENTS
Tubes in Ears
Caesarean Section
Episiotomy
Hernia
Hysterectomy
Dental Surgery
Other: (describe)
Other: (describe)
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
18
Establishing Health Goals
Personal Message
Before we begin our journey together, I would like to talk about something very important that will have a major impact on your
ability to achieve maximum improvement in your health. After many years in private practice, I have had the opportunity to work
with thousands of patients and have seen many achieve significant improvement while others have become frustrated and not
achieved the results they were hoping for.
After careful reflection, I have identified some of the most common reasons why some people succeed in improving their health and
others don’t. This questionnaire is about much more than eliminating your symptoms – it’s about living a life of vibrant health.
I’ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality; a discussion of how you
have lived your life up to this point and how you will live it in the future.
Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions. I want
you to be honest with yourself and dig deep inside for the answers that best describe how you really feel.
What do you hope to achieve in your visit with us?
If you had a magic wand and could erase three problems, what would they be?
1.
2.
3.
Are you deeply committed to changing everything in your life that is keeping you from achieving your health goals?
YES
NO
You have likely read this statement before: “The definition of insanity is to keep doing the same thing and expecting a different
result”. Most people I ask tell me they have made the decision to change; yet many will struggle to make the needed changes.
Why? Because there is a big difference between just deciding something and having “reasons” to actually do it. When you have
made a decision to make a change and you know your reasons too, you create an internal power and strong motivation that can
propel you towards achieving health and wellness.
So now I ask you to think about the following:
Please list up to 6 things that you have been unable to do as a result of your present symptoms:
1.
4.
2.
5.
3.
6.
And also now, please list up to 6 things that you plan to do once you are feeling better:
1.
4.
2.
5.
3.
6.
Are there any other health goals you want to achieve?
Describe:
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
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Readiness Assessment
In order to improve your health, how willing are you to do the following?
Please rate on a scale of: 1 (not willing) to 5 (very willing).
Choose Number from Drop Down List:
...1... Significantly Modify Your Diet
...1... Take Several Nutritional Supplements Each Day
...1... Keep a Record of What You Eat Each Day
...1... Modify Your Lifestyle (e.g. work demands, sleep habits)
...1... Practice Relaxation Techniques
...1... Engage in Regular Exercise
...1... Have Periodic Pathology Tests to Assess Progress
...1... Invest Time Into Educating Yourself About Your Own Health Issues
Any Other Comments:
Q. How confident are you of your ability to organise and follow through on the above health related activities?
Please rate on a scale of: 1 (not confident at all) to 5 (very confident).
Choose Number from Drop Down List: ...1...
Q. If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully
engage in the above activities?
Please Describe:
Q. At the present time, how supportive do you think the people in your household will be to your implementing the above
changes?
Rate on a scale of: 1 (not supportive at all) to 5 (very supportive).
Rate: ...1...
Any Other Comments?
Thank you for taking the time to complete this health history questionnaire; the information derived provides invaluable data
allowing me the opportunity to discover any “missing keys” that could potentially significantly help you to find the cause of any
imbalances, manage your health problems and obtain improvements.
Once all the sections of this form and the questionnaires have been filled out please return them to our office in preparation for your
initial consultation. I look forward to helping you achieve a “return to health and wellbeing”.
In good health,
Dr Sandeep Gupta
Lotus Holistic Medicine | © Dr Sandeep Gupta 2014
20