ealth Consultation Form


1) What is your main goal?
2) Are you under treatment or taking any medication? Please, specify dosage and for what condition.
3) How would you rate your stress level?
8) Has your doctor ever told you that you have high cholesterol, heart condition or cardiovascular disease? please, specify.

9) How is your blood pressure? 


10) How about your blood sugar? 

11) Do you experience reproductive hormonal imbalance symptoms such as fluid retention, weight gain, acne, mood swings, night sweats, heavy periods or irregular periods?
4) Do you have problems sleeping?

5) Estimate how many hours of sleep you have each night on average.

12) Do you have any digestive issues such as stomach bloating, diarrhoea & constipation?

6) How often do you exercise?

7) Do you have any pain or injury? Explain
13) Check the appropiate condition

14) How did you hear about us?


If you have any questions or want to share further medical information, go ahead:

HQ Downtown - 67 Willow Street, Tauranga 3110                                                                                           we@healthquarters.co.nz  Te Puna - 17b Minden Road, 3172