Register Now – Guided Health

Register Now!

Tell us a little bit about yourself.

Registration does not cost anything. We will contact you in 24 hours to discuss the best path for you.

Alternatively, you can purchase our 'Guided Consultation Package' or download our 'Starter Guide' for an immediate kick off!

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Registration Form

This is your first step

Name *

Phone *

Address

Apt, suite, etc.

Country

City

State

Zip code

Date of Birth

Email *

Height

Weight

Blood Type

Sex

Male

Female

Main reason for visit

Date of last GP visit

Blood tests done

Specify; Name of Drug/Supplement, Strength, Frequency Taken & Date Started

List all medicines that you are currently taking (include medicines such as prescribed drugs, over-the-counter drugs, vitamins, and inhalers):

Specify; Name of Drug/Supplement & Reaction You Had

List each of the medications that you are allergic to, and the reaction that you experienced from taking the medications:

Are you Pregnant?

Yes

Have you got private health insurance?

If yes, with who?

What are your health goals?

Rate your excercise

Sedentary (no excercise)

Mild excercise (climb stairs, frequent walks, golf)

Ocassional vigorous excercise(less then 3 times per week for 30 mns

Regular vigorous excercise(More then 3 times per week for 30 mns

Do you drink cofee?

If yes, how much?

Do you drink tea?

If yes, how much?

If yes,

What type?

Do you currently use tobacco?

Yes

Socially

Do you use illicit drugs?

Yes

Sometimes

In the past

D you drink alcohol?

If yes, how much?

By ticking this box, I confirm all information supplied is correct

Contact Us

Contact: Kimberly Miller

Address:
1b Michael Street
Brunswick, VIC 3056

Phone: 0433 300 513

Email: info@guidedhealth.com.au

Web: www.guidedhealth.com.au

Register Now!

Registration Form

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