Initial Consult Form

About
Contact Us

    Your Name (required)
    E-mail (required)
    Emergency Contact (required)
    Address (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.

    Do you suffer any of the following symptoms?
    Please rate them on a scale of 0-5 (0 being never and 5 being severe/persistent) Please be careful to fill out all sections.
    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



    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



    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


    I agree that all of the information given in this form is true and correct.
    I shall advise my practitioner of any health changes.
    I Agree