2. Questionnaire – Zenith Clinics

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Last Name

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Any information you provide today is confidential and compliant with the Medical Board of Australia Good Medical Practice code, RACGP Standards of General Practice and our Medical Confidentiality Duty of Conduct for doctors in Australia, which means we protect your privacy and right to confidentiality.

What was your gender at birth?(Required)

What prescription or non-prescription medications do you take, including doses (if any)?(Required)

What allergies do you have (if any)?(Required)

What condition or symptom are you having issues with?(Required)

Are you planning to have children in the near future?(Required)

Yes

Do you suffer from psychosis, bipolar disorder or schizophrenia?(Required)

Yes

Do you suffer from any cardiovascular diseases, including irregular heartbeat (arrhythmia)?(Required)

Yes

Do you have an addiction to any psychoactive substances and/or drugs, including alcohol, but excluding nicotine and caffeine?(Required)

Yes

In order to be suitable for Alternative Medicine, we need to identify whether you have attempted to treat your condition in at least two different ways, over a three month period.

Please add the first medication, treatment or therapy you trialled.(Required)

Please add the second medication, treatment or therapy you trialled.(Required)

Have you discussed other treatment options with your doctor? Including medical and conservative therapies.(Required)

Yes

Knowing the alternative management options, do you still want to trial Alternative Medicine as a treatment option for your condition?(Required)

Yes

Are you aware of how Alternative Medicine can potentially affect your ability to operate machinery, equipment, and vehicles (including trains, planes and automobiles)?(Required)

Yes

Does your workplace require you to undertake drug screening?(Required)

Yes

The Alternative Medicine we offer is a depressant drug that slows down the activity of the central nervous system, including the brain. It can also have mild hallucinogenic effects. Long-term use of Alternative Medicine has been linked to anxiety and depression. Heavy Alternative Medicine use can affect your memory and how clearly you think. It may also increase the risk of paranoia and hallucinations.

Do you feel that you know enough about the short and long term side effects of alternative medicine?(Required)

Yes

Have you used Alternative Medicines before, whether for medicinal reasons or otherwise?(Required)

Yes

Please be aware: If you have a current, active prescription with another Alternative Medicine provider you will be required to provide a discharge letter.