apply to 4yhealth - health intake questionnaire

As an Integrated Health Practitioner, I look at all the facets of someone’s life, past and present, that could have affected their health. You may find this intake form a lot longer, and a lot more personal than any you have completed in the past. This helps me develop a more complete picture of your health far beyond what you would experience at a typical doctor’s appointment. We can then work together to develop a Personalised 4YHealth Plan that suits you and your lifestyle and gets you back on the path to health. As such, please try to answer all questions to the best of your knowledge and ability. I appreciate you taking the time to take this first step.

Once submitted, I will be in touch within 48 hours to discuss the best course of action going forward. Alternatively, you can Book Now and I can have you fill out the form later. The form must be completed a minimum of 24 hours before your scheduled appointment in this case.

Which service are you applying for? *
Name *
Name
Today's Date *
Today's Date
Address *
Address
Please include your country code (eg. +1 for Canada) before your number if you are located outside Australia
Please register for Skype if you do not have an account. If not possible please specify below.
Date of Birth *
Date of Birth
Gender *
How did you find me? *
Did you feel safe growing up? *
Have you been involved in abusive relationships in your life? *
Was alcoholism or substance abuse present in your childhood home,or is it present now in your relationships? *
Do you feel safe, respected and valued in your current relationship? *
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *
Were you a full term baby? A preemie? Breast-fed or Bottle-fed? *
Please select all that apply
Leave this one blank and fill in below please
Think in your tea/coffee, and any other added sugar, not natural sugars like those found in fruit and veg.
How many bowel movements (BM) do you have per day typically? *
Are you exposed to second hand smoke regularly?
Have you, to your knowledge, been exposed to toxic metals in your job or at home? *
0 being the lowest, 10 the highest. Think of you work/life balance, your relationships, current health concerns...
How much sleep do you get per night on average? *
Have you ever had psychotherapy or counseling?
Are you currently, or have you ever been, married? *
Please select all the apply
I have read and understand everything on this page. I acknowledge Ryan Barby does not diagnose, cure, or treat any illness or disease. Further, by checking the "I Agree" button below I release Ryan Barby from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their natural health services. *
Waiver

Congratulations, you are on the path to taking your first step towards health and wellness!

* All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.