Intake Page 3 Full Name Email DIETARY OVERVIEW Dietary Considerations NoneIntolerantSensitiveAllergicOther NoneLactoseGlutenDairyOligosaccharidesDisaccharidesMonosaccharidesPolyolsSalicylatesAminesGlutamatesPreservativesNitritesArtificial Colours/FlavoursEggsPeanutsShellfishCornSoyMeatCoffeeAlcoholRed MeatCurryGreasy FoodGarlicOnionsLegumesCarbohydratesCruciferous VegetablesSugarSaltChocolateCarbohydratesFatsOther Special Diets NoneOrganicVegetarianVeganPescetarianCarnivoreLow CarbFODMAPGAPSPALEOKetogenicAtkinsMediterraneanHalalKosherFasting Special Diet and Considerations NoneFrequent DietingWeight Loss ShakesCan't Gain WeightCan't Lose WeightBinge EaterEmotional EaterBulimiaAnorexiaPoor AppetiteAlways HungryOther Daily Water Intake No Water1 cup - 230ml2 cups - 470ml3 cups - 700ml4 cups - 940ml5 cups - 1100ml6 cups - 1400ml7 cups - 1650ml8 cups - 1890ml9 cups - 2120ml Water Source Tap WaterFiltered WaterMineralised Water System Fluid Intake NoneCoffeeBlack TeaGreen TeaHerbal TeaSoft DrinkCarbonated DrinksKombuchuCokePepsiAlcoholCordialEnergy DrinksOther FLUID Volume None1 cup - 230ml2 cups - 470ml3 cups - 700ml4 cups - 940ml5 cups - 1100ml6 cups - 1400ml7 cups - 1650ml8 cups - 1890ml9 cups - 2120ml Fluid Intake NoneCoffeeBlack TeaGreen TeaHerbal TeaSoft DrinkCarbonated DrinksKombuchuCokePepsiAlcoholCordialEnergy DrinksOther FLUID Volume None1 cup - 230ml2 cups - 470ml3 cups - 700ml4 cups - 940ml5 cups - 1100ml6 cups - 1400ml7 cups - 1650ml8 cups - 1890ml9 cups - 2120ml Fluid Intake NoneCoffeeBlack TeaGreen TeaHerbal TeaSoft DrinkCarbonated DrinksKombuchuCokePepsiAlcoholCordialEnergy DrinksOther FLUID Volume None1 cup - 230ml2 cups - 470ml3 cups - 700ml4 cups - 940ml5 cups - 1100ml6 cups - 1400ml7 cups - 1650ml8 cups - 1890ml9 cups - 2120ml Other FLUIDs Previous Next TREATMENT OBJECTIVES Current Health Concern(s) Health Goals CLIENT Informed CONSENT I accept and consent to the following: I acknowledge that my health information is recorded in a medical electronic file and, if required, shared between other healthcare providers I acknowledge that services provided to me are under the instructions of the treating Health Practitioner I certify that the information that I have supplied is correct and accurate to the best of my knowledge I agree to inform of any changes in my personal or health details I agree that I have read / or will read the information regarding consultation, assessment and treatment accessible under the "consultation" menu on EHA's website In the event of emergency or other, I consent to the release of my medical information to my contact support person as listed above. Client Signature: Please provide YOUR signature AND/OR Guardian Name and Signature (If applicable) Previous Next
