How to complete this form

Fill in the form below on your phone, tablet or computer, then press the Submit Form button at the end — your answers are sent straight to the clinic, no printing or emailing required.

Please complete and submit at least 48 hours before your appointment, and email any test results separately to health@cassandrahilton.com.

New Patient Form

Thank you for choosing Cassandra Hilton. Please complete the following and submit at least 48 hours prior to your appointment.

Your Details

First Name

Last Name

Street Address

Suburb

State

Post Code

Date of Birth

Occupation

Marital Status

Mobile

Home/Work Phone

Email Address

Private Health Fund

Number & Age of Children (if applicable)

How did you hear about us?

Our website / Google Brochure/flyer Social Media Referral (name):

Current Health Practitioners

e.g. GP, Chiropractor, Psychologist

Your GP's Name

Clinic Address

Clinic Phone Number

Other Practitioner Name

Clinic Address

Clinic Phone Number

Emergency Contact Details

Name

Relationship

Phone Number

Current Health Concerns

Please list up to 5, in order of priority

Current Health Goals

Current Medications & Supplements

What medications are you currently taking?

Medicine Name	Dose & How Often	How Long Have You Taken This?

What nutritional, herbal or other supplements are you currently taking?

Item Name & Brand	Dose & How Often	How Long Have You Taken This?

Do you have any allergies or intolerances? Please indicate and provide details of reaction.

Food Allergies/Intolerances (e.g. gluten, dairy, sulphur)

Environmental Allergies (e.g. dust mite, animals, mould)

Medicine/Supplement/Herb Allergies

General Health History

Have you been diagnosed with any medical conditions?

Diagnosed Medical Condition	Date/When	Who Diagnosed You?

Systems Review

Please select the option that best describes how often you experience each symptom.

Head, CNS

Symptom	Never	In the past	Sometimes	Often
Headaches
Migraine
Dizziness
Fainting
Memory Loss
Seizures
Convulsions
Loss of balance
Poor coordination
Numbness
Poor concentration
Coldness

Ear, Nose, Throat

Symptom	Never	In the past	Sometimes	Often
Deafness
Ear noises
Waxy ears
Ear aches
Sinusitis
Loss of sense of smell
Blocked nose
Colds
Hay fever
Allergies
Sneezing
Swollen glands
Ear infections
Nose bleeds
Noise sensitivity

Mouth, Teeth, Gums

Symptom	Never	In the past	Sometimes	Often
Toothache
Lost or loose teeth
Abscess
Ulcers
Mercury amalgams
Bleeding gums
Grinding teeth
Metallic taste in mouth
Cold sores
Cracks around mouth
Can't taste foods
Bad breath

Skin, Hair, Nails (general)

Symptom	Never	In the past	Sometimes	Often
Acne
Eczema
Psoriasis
Hair loss
Warts
Excessive sweating
Slow to heal
Rashes
Itching
Redness
White spots on nails
Ridges on nails
Nails chip or peel easily
Sweat has a strong odour
Hair thinning
Facial hair (females)

Digestive System

Symptom	Never	In the past	Sometimes	Often
Indigestion
Bleeding
Burping/belching
Nausea
Acidity
Sugar cravings
Carbohydrate cravings
Salty food cravings
Bad breath
Vomiting
Bloating
Constipation
Diarrhoea
Haemorrhoids
Fissures
Flatulence
Stomach pain
Abdominal pain

Urinary System

Symptom	Never	In the past	Sometimes	Often
Frequent urination day or night
Frequently thirsty
Burning
Infection
Restricted flow
Blood in urine
Strong odour
Night urination
Lower back pain
Kidney stones

Female System

Symptom	Never	In the past	Sometimes	Often
PMT/PMS
Hot flushes
Menopause
Menstrual irregularities
No menstruation
Loss of libido
Discharges
Infections
Difficulty conceiving
Breast lumps
Breast tenderness
Herpes
Other STD, warts
Fibroids

Male System

Symptom	Never	In the past	Sometimes	Often
Erection concerns
Sciatica
Prostate issues
Issues with urine stream
Herpes
Other STD, warts
Lower back pain
Difficulty conceiving
Infections
Thrush

Family History

Mark X for conditions you or a family member have experienced. Mark D if the family member passed away from this illness. Examples: thyroid, cardiovascular, cholesterol, clotting/bleeding disorder, urinary/kidney issues, migraines, cancer (specify type), diabetes, depression, anxiety, bipolar, OCD, weight issues, eating disorder, chronic fatigue, arthritis, allergies, Crohn's, coeliac, liver problems, IBD, Alzheimer's, dementia, addiction, schizophrenia, asthma, blood pressure, Parkinson's, MS, autism, ADD, Asperger's, skin cancer, psoriasis, eczema, and other skin conditions, endometriosis, PCOS, and acne.

Condition	You	Mother	Father	Sibling	Your child	Maternal G/Father	Maternal G/Mother	Paternal G/Father	Paternal G/Mother

Digestion

How often do you have a bowel movement?

Do your stools float or sink?

What colour are your stools?

Any blood, mucous, or undigested food in the stool?

Details of any issues you've had with bowels or digestion in the past

Female Reproductive System

What age did you get your first period?

If not menstruating, what age did you go through menopause?

If menstruating, is your cycle regular and how many days? (e.g. every 28 days)

How many days do you bleed?

What is the blood flow like? Do you get any clots?

Do you get any PMS? (sore breasts, mood, pain, anxiety, cramps) Please provide details

What warts, viruses, thrush, herpes, infections do you get and how often?

What contraception method do you use (if any)?

Could you be pregnant?

How many pregnancies have you had?

Have you had any issues trying to conceive?

When was your last pap smear, and have you had any abnormal pap smears currently or in the past?

Blood Pressure

Is your blood pressure normally high or low? If known, please indicate your current reading

Mood and Cognition

Anxiety

Do you suffer from anxiety or panic attacks?

What is your anxiety level? (0 = low, 10 = high/panic attack)

What symptoms do you experience with your anxiety? (sweating, palpitations, phobias)

When is it worse?

When/what makes it better?

What started your anxiety?

How long have you experienced anxiety?

Depression

How would you rate your mood? (0 = can't get out of bed, 10 = extremely happy)

When is it worse?

When is it better?

What started your depression?

How long have you experienced depression?

Cognition

Do you get a foggy head?

Do you feel like you cannot think properly?

Do you forget words, or have difficulty expressing yourself?

Have you taken medication in the past for your mood? If so, please indicate what and when

Lifestyle

Energy Levels

How would you rate your energy levels? (1 = lowest, 10 = highest)

Do you experience changes in energy during the day? If so, what time?

What is your best time of day, and what is the worst?

Have you had any periods of significant fatigue? Please provide details

Sleep

How many hours of sleep do you have on average each night?

Do you have any sleep problems? (e.g. getting to or maintaining sleep) Please provide details

Do you wake refreshed, or have difficulty waking up? Please provide details

Weight

Current weight

Current height

Have you had any weight issues? Please provide details

Have you gained or lost weight in a short period of time?

History of eating disorders? If yes, please provide details

Exercise

What exercise do you do, and how long/often per week? (e.g. weights, walk, run, swim, yoga)

What do you do to relax? (e.g. read, swim, sleep, yoga, podcasts)

Stress

How would you rate your current stress levels? (1 = low, 10 = high)

What experiences, if any, have been a major stress in your life? (e.g. death, divorce, bankruptcy)

Diet

Beverage	How Much	How Often
Water
Alcohol (specify)
Tea/Coffee
Soft Drinks
Other

What do you consume on a typical day?

Breakfast

Lunch

Dinner

Mid-Morning

Mid-Afternoon

Snacks

Cravings / foods that make you feel good

Aversions / foods you avoid or that make you feel unwell

What diet restrictions do you have currently or have had in the past? (e.g. vegetarian, paleo, gluten free)

Environment

Do you or have you ever smoked?

Yes No How often/how long:

If yes, please provide details

Are you exposed to passive smoke, or have you lived with a smoker?

Yes No How often:

Do you currently or have you in the past used recreational drugs? If yes, please provide details

Have you ever lived or worked in a water-damaged or damp building? (flooding, damp, leaking, mould)

When & How Long For?	Location/Details

Have you ever been bitten by a tick or spider, or experienced an unknown rash/bite?

What was it?	When did it occur?	What did the rash/reaction look like?

Have you travelled overseas?

Where	When	Any health issues?

Have you been exposed, in current or past occupations/home/activities, to chemicals, fumes, paints, plastics or gases? (e.g. hairdresser, painter, dentist, farming, renovating) Please provide details

Skin

Skin Clients Only — To Complete

Not a skin client? Skip to Consent & Agreement →

This section applies the same clinical framework used across our skin health programmes — genetics, hormones, gut, diet, stress, sleep, systemic health, environment and lifestyle. The more detail you provide, the more targeted your assessment and protocol can be.

Primary Concern

Age at onset

Duration (how long has this been present?)

Location on body (be specific — e.g. forehead, jawline, chest, back, scalp)

Current severity (1 = mild, 10 = severe)

Pattern & Triggers

Does it follow a cyclical pattern linked to your menstrual cycle?

Is there a seasonal pattern?

Does it visibly worsen with stress?

Does it worsen after specific foods? If so, which?

Does it worsen after using specific products? If so, which?

Previous Treatments Tried

Treatment (topical, oral, or procedure)	Duration Used	Effectiveness / Side Effects

Current Skincare Routine

Morning routine (products used, in order)

Evening routine (products used, in order)

Active ingredients currently in use (e.g. retinol, vitamin C, AHA/BHA, benzoyl peroxide, niacinamide)

How long have you been using your current routine?

Sun Exposure & Photoprotection

Do you use SPF daily?

Approximate weekly sun exposure (hours)

History of sunburn (frequency, severity)

History of tanning bed use

Family History — Skin Specifically

Do your parents or siblings have a history of acne, eczema, psoriasis, rosacea, skin cancer, or notably premature skin ageing? Please specify who and what.

Hormonal Correlation

Does your skin change with your menstrual cycle?

Did your skin change during or after pregnancy?

Has your skin changed after starting or stopping hormonal contraception? Please provide details

If perimenopausal or menopausal, have you noticed skin changes during this transition?

Gut & Digestive Correlation

Does your skin flare after specific foods or in relation to digestive symptoms (bloating, irregularity)?

Have you noticed skin changes after a course of antibiotics?

Stress & Sleep Correlation

Does poor sleep correlate with flares? If so, how many days after a bad night's sleep does a flare typically appear?

Does your skin visibly worsen during stressful periods?

Genetic & Testing History

Have you had any genetic testing done previously (skin-related or general)?

Would you be interested in genetic testing relevant to skin health?

Photography Consent

Yes, I consent to clinical progress photos being taken and stored securely in my file No, I do not consent to progress photos

Your Skin Goals

What would clinical success look like for you? (be as specific as possible)

Full Name (typed)

Signature (type your full name to confirm)

Date

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Please submit your completed form at least 48 hours prior to your appointment.

Symptom	Never	In the past	Sometimes	Often
Light sensitivity
Blurred vision
Red eye
Puffy eye
Watery eye
Painful eye
Eyebrows thinning

Symptom	Never	In the past	Sometimes	Often
Aching
Tension
Arm Pain
Muscle pain
Tingling
Cold hands/feet
Joint pain
Numbness
Cramps
Stiffness

Symptom	Never	In the past	Sometimes	Often
Post nasal drip
Chronic cough
Wheezing
Asthma
Shortness of breath
Chest pain
Chest tightness
Palpitations