Consultation Form

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Postcode

Country

Phone/Mobile

Date of Birth

Occupation

Height (cm)

Weight (kg)

Next of kin Name & Phone no

Please summarise the health concerns that you would like to address

Have you tried any other form of treatment? If yes, give details above.

Goals from your naturopathic treatment (can be completed with naturopath during consultation)

List any medication and/or supplements you are currently taking or have recently taken

List any other significant illnesses in your life and age of onset

List any emotional traumas/episodes, with dates (roughly), as far back as you like (Divorce, Bereavements, Parents split, Accidents, Injuries, etc) or any other relevant information

Do you have any allergies? Please include your symptoms

Tick the box if you regularly suffer from any of the following symptoms:

Digestion

Bloating

Constipation

Wind

Diarrhoea

Acid Reflux

How frequent are your bowel movements? (x per day)

Cardiovascular / Respiratory

Chest Pain

Shortness of Breath

Asthma

Hayfever

Dizziness

Varicose Veins

Please state any other heart/lung conditions

Musculoskeletal

Osteoarthritis

Rheumatoid Artritis

Back Pain

Muscle Cramps

Restless Leg

Joint Pain

Skin

Eczema

Dermatitis

Psoriasis

Acne

Dry/Greasy Skin

Dandruff

Dark circles under the eyes

Menstruating Women

PMT

Menstrual Bloating

Heavy Flow

Irregular Cycle

Painful Periods

Depression

Fluid Retention

Do you track your cycle, if so how many days in your cycle?

If you haven't already, state any other challenges you have with your menstrual cycle (including conditions such as endometriosis, PCOS, etc.

Perimenopausal Women

Hot Flushes

Mood Swings/Irritation

Depression and/or Anxiety

Poor Sleep

Vaginal Dryness and/or Genitourinary symptoms

Sex Drive - mental or physical

Memory and Cognition issue

List any other challenges:

General Health

Headache

Migraines

Athletes' Foot

Cold Sores

Lack of Sex Drive

Low Fertility

Poor Memory

Poor Night Vision

Poor Sleep

Poor Wound Healing

Thrush

Sensitive to bright lights

How many hours sleep do you get per night?

Do you wake feeling refreshed? Yes or No

Yes

Energy Levels - Describe how you feel other times during the day (ie: mid day, afternoon and in the evening?

What are your stress levels on a scale of 1-10 (1=None, 10=About to blow a gasket!)

What do you do for exercise/rest/relaxation?

List any significant family history of illness/disease

Do you have any food intolerances? Please include your symptoms

Provide details of the foods you most often eat and state any meals you often skip.

Breakfast Time

Mid-Morning Snack

Lunchtime

Mid-Afternoon Snack

Dinnertime

Evening Snack

Cravings

Foods You Dislike

Drinks throughout the day

Water (litres per day)

Tea (cups per day)

Coffee (cups per day)

Soft drink (cans or glasses per week)

Wine (glasses per week)

Beer (glasses per week)

Spirits (glasses per week)

Other. Please specify drink and how often consumed

Have we missed anything? Is there anything else you would like to tell me?

I have read and agree to the Terms and Conditions and Privacy Policy

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Consultation Form

Heal yourself naturally