Thank You and Next Steps

Thank you for purchasing an annual subscription with Dr Cindy de Villiers at Health Function.

Your registration is confirmed.

I look forward to meeting you and working together to optimise your health.

Next Steps

Please provide your medical history using the form below. You may want to bookmark this page in case you need to return to it.

Before your first appointment, we will set up your medical file with your history, preferences and consents.

Look out for an email confirming your appointment and providing directions to the clinic.

At your first appointment, you will be registered for MyIndici, your patient portal. Please bring in a photo ID, to complete your registration.

Medical History

First Name

Middle Name

Last Name

Preferred / Nick Name

Gender

Phone Number (preferably mobile)

Next of Kin / Emergency Contact: Name

Next of Kin / Emergency Contact Phone Number (preferably mobile)

Postal address - If different to your home address.

Do you currently use MyIndici with another practice

Yes

Is the email address provided above aleardy linked to your existing MyIndici account?

Yes

Please provide an alternative email address. This will be your Health Function registration email and will also be used to set up your MyIndici Login with Health Function. Health Function holds only one email address on recoord. Your existing MyIndici login with your other practice will not be affected.

Which is your preferred pharmacy? Please state name and address.

What is your main health concern?

Medical Timeline

Adaptive Opportunities

Vaccinations

Regular Medications

Supplements

Family History

How many alcoholic drinks would you usually drink in a month?

Do you use any recreational drugs, including vapes?

Type and Frequency?

Exercise

Please list work / occupations you have undertaken.

Relationship Status

Home Environment

Is violence at home or work/school a concern for you?

Have you had any adverse reactions (side effects or allergy) to medication or anything else? If so please describe.

Have you ever smoked tobacco?

Please state how many cigarettes / grams for how many years.

Do you feel you have purpose in life? From where do you derive meaning?

Anything else you want to add?