NATUROPATHY

INTAKE FORM

Welcome To Your Naturopathic Health Questionnaire

Please take the time to fill this questionnaire out as honestly and accurately as possible, which will allow us to provide you with the most appropriate naturopathic care. All information given is strictly confidential.

Name*

Date of Birth*

Address, Suburb, State & Postcode*

Home Phone

Work Phone

Mobile

Email Address*

Marital Status*

Married / De Facto

Not Married / Widowed

How did you hear about our clinic?*

Do you have children?*

Yes

What ages are your children?

Current Occupation*

Previous Occupation*

Would you like to receive our newsletter?*

Yes

What is the reason for your visit / main concern?*

What are your symptoms? Please list:*

How do you rate your health? (1-10) 10 being the best*

Has this condition been medically diagnosed? If so, by whom & when?*

How long have you had this condition / symptoms for?*

What treatment(s) have you received / tried in the past for this?*

List any other health concerns you would like to improve:

Are you allergic / intolerant to medications, foods or chemicals in food or the environment? Please detail if so. (E.g. nuts, wheat, dairy, gluten, salicylates, pollen, dust, animal fur / hair)

What doctor prescribed / over-the-counter medications are you taking? Please state medication name, strength dosage, date of first use & reason for taking.

What supplements / herbal supplements are you taking? Please state brand, dosage, date of first use & reason for taking.

Informed consent for naturopathic care

I declare the information above is true and correct and indemnify Inside Out Clinic of any liability for any false or misleading statements given. I understand and accept that the naturopathic treatment received by your office is of a holistic, ther*