Please forward previous blood test report, Dexa Scans, etc,. admin@bestuclinic.com.au

Do you participate in any sports or engage in physical hobbies. If yes, please provide details:

Please List the following:

PAST SURGERY – please list ALL surgery you have had and the YEAR it occurred

PAST MEDICAL HISTORY – please list ALL medical problems you have had and the YEAR they began. Please * any work-related injuries and note if it is a worker’s compensation claim

ALL MEDICATIONS/NUTRIENTS – please list ALL script medications, vitamins, minerals, herbals, etc. Dosage and time taken.

ALLERGIES – please list ALL allergies you have, including allergies to medications, vitamins, minerals, herbs, food, etc.

FAMILY HISTORY - Please indicate whether there is a history of the following conditions in your family: heart disease, high blood pressure or circulatory conditions, cancer, diabetes, osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, multiple sclerosis, muscular dystrophy, mental illness, auto-immune disorders, asthma, allergies, psoriasis, eczema, alcoholism, drug abuse or any other conditions that are pertinent to your present state of health.

Smoking and Alcohol

Your Current Physical Health on a scale 0-10, where (10 highest)

What exercises are part of your typical routine?

Your Current Mental Health on a scale of 0-10 (10 highest)

Please list the three most significant stressful events in your life. Indicate those continuing to impact your life.*

Have you had any of the following health issues in your life. Please tick ‘✓’ the appropriate column

Have you had

Do you suffer from any of the following symptoms (please place tick in the appropriate column)

Symptom

What is the main condition for seeking treatment with us? Please describe the symptoms and concerns. List the very first time you noticed the condition and describe carefully anything that you suspect may have played a role in the development (e.g. Stress, Injury, Lifestyle changes etc).

Consent:

Accuracy of Information

I confirm that the information provided in this form is true, complete, and accurate.

Consent to Examination and Treatment

I hereby give consent to the medical team and staff to conduct examinations and/or treatment deemed necessary.

Eligibility Declaration

I declare that I am over 18 years of age and I am NOT under any sporting or professional code where the treatments or medicines offered are prohibited.

Off-Label and Non-ARTG Treatment Acknowledgemen

I am aware and consenting to a treatment that may not be included on the Australian Register of Therapeutic Goods (ARTG), has not been evaluated by the Therapeutic Goods Administration (TGA), and may be prescribed for an off-label indication.

While your clinician believes this treatment is appropriate based on your individual circumstances, you acknowledge that not all potential risks are known.

Consultation Fees and Refund Policy

All consultations are provided as a professional medical service and are non-refundable once delivered.

Additionally, all medications and compounded products are strictly non-refundable, including once dispensed or dispatched by the pharmacy, due to regulatory and safety requirements.

Medicare & Private Health Insurance Rebates

I acknowledge that Medicare and private health insurance rebates are not available, as services may involve both approved and unapproved holistic therapies delivered as part of an integrative treatment approach.

Prescriptions and Medication Supply

I understand and agree that all prescriptions issued by the clinicians at BestU Clinic will be sent directly to our partnering pharmacy for compounding and dispensing.