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)
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.
Constant Fatigue 12345 Poor sleeping patterns 12345 Waking fatigued 12345 Energy slumps during the day 12345 Feeling anxious or upset 12345 Mood swings 12345
Poor memory & concentration 12345 Not thinking clearly 12345 Anger & irritability 12345 Cravings due to fatigue 12345
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
Acne 12345 Hives or rashes 12345 Eczema/ dermatitis/ psoriasis 12345 Fungal infections 12345 Sensitivity to skincare products 12345
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
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
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
