Initial Consultation Form – Redlands Naturopathy Clinic

Your Name (required)

Phone (required)

E-mail (required)

Address (required)

Date of Birth (required)

Occupation (unrequired)

Age (required)

Emergency Contact (required)

Emergency Phone (required)

General Practitioner Name (required)

Presenting Complaint

What is the main health concern that brought you to a naturopathic clinic? When did it first start? (required)

Please list all previous treatments for your health complaint. (required)

Do you have any allergies or intolerances? Eg. foods, dust mites, medicines etc (required)

Have you had any operations? When? (required)

Please list any illnesses you’ve had in the past and at what age you had them eg. tonsilitis, ear infections etc (required)

Are you currently taking any medication? If yes, please write for how long and dosage.

Are you currently taking any supplements? Which brand? Dosage?

Please list any illnesses in your family (diabetes, cancer, others)

Have you had any blood tests or other types of investigations done in the last 12 months? Please bring these to your initial consultations.

Please indicate if you suffer any of the following symptoms and rate them on a scale of 0-5 (0 being never and 5 being severe/ persistent)

Energy/ Activity

Constant Fatigue 12345
Poor sleeping patterns 12345
Waking fatigued 12345
Energy slumps during the day 12345
Feeling anxious or upset 12345
Mood swings 12345

Mind

Poor memory & concentration 12345
Not thinking clearly 12345
Anger & irritability 12345
Cravings due to fatigue 12345

Digestive System

Nausea or vomiting 12345
Diarrhoea or loose stools 12345
Constipation 12345
Bloated feeling 12345
Belching, passing gas 12345
Heartburn 12345
Abdominal pain or cramping 12345
Haemorrhoids 12345
Mucous or blood in stools 12345
Loss of appetite 12345

Skin

Acne 12345
Hives or rashes 12345
Eczema/ dermatitis/ psoriasis 12345
Fungal infections 12345
Sensitivity to skincare products 12345

Eyes, Nose, Mouth & Throat

Watery or itchy 12345
Swollen or red 12345
Difficulty breathing through nose 12345
Sinus problems 12345
Hay fever 12345
Excess mucous formation 12345
Chronic cough 12345
Frequent need to clear throat 12345
Swollen or coated tongue 12345
Cracks in the corner of mouth 12345
Frequent illness 12345

Muscle

Pain or aches in joints 12345
Muscle fatigue 12345
Stiffness or limitation of movement 12345
Pain or cramping in muscles 12345
Physical trauma/ accidents 12345
Osteoporosis 12345

Reproductive and Urinary

Frequent urination day/ night 12345
Recurrent UTI 12345
Prostate problems 12345
Kidney problems 12345
STDs 12345
Menopausal symptoms 12345
Irregular menstrual cycle 12345
Excessive bleeding 12345
PMT/ PMS 12345
Low libido 12345

I agree that all of the information given in this form is true and correct. I shall advise of any health changes or new information as it comes.

I agree