Alexandra Audrey Wellness - Intake Form
Date
*
/
Day
/
Month
Year
Todays Date
Name
*
First Name
Last Name
Parents Name
First Name
Last Name
Address
*
Address
Address Line 2
City
State
Postal Code
E-mail
*
example@example.com
Referred By
Mobile
*
Mobile preferred
Home Number
-
Country Code
-
Area Code
Phone Number
Work Number
-
Country Code
-
Area Code
Phone Number
Date of Birth
*
-
Day
-
Month
Year
Date
Occupation
Please accept the following:
*
I acknowledge the collection of my personal information, including sensitive information, for the purposes set out within.
Please be aware that if you miss an appointment, cancel or change an appointment with less than 48 hours’ notice, you will be charged the full appointment fee. Tick the box to acknowledge that you have read and understand the Terms.
Tick to agree to SMS and email communication.
Back
Next
What is your main reason for seeing a naturopath
Please list any pre-existing conditions
Are there any diseases that run in the family
Current medications and duration of use
Anything to note form last blood tests
Current vitamins, minerals, herbs or supplements that you take
How many times do you poo
Rows
Quantity
In a day
In a week
Have you ever had?
Digestive System
Rows
Never
In the past
On Occassion
More info
Bloating after meals
Excessive flatulence
Constipation
Diarrhoea
Heartburn/reflux
Nausea
Respiratory System
Rows
Never
In the past
On occasion
Often
More Info
Asthma
Hayfever
Colds/coughs in winter
Sinus infections
Ear infections
Sore throat
Cardiovascular System
Rows
Never
In the past
On occasion
Often
More Info
High blood pressure
Varicose veins
Cold hands and feet
Raised cholesterol
Female Reproductive System
Rows
Never
In the past
On occasion
Often
More Info
PMS (anger, sadness, anxiety)
Menopausal symptoms
Erratic cycle
PCOS
Endometriosis
Heavy periods
Painful periods
Breast tenderness
Fluid retention
Ovulation pain
Abnormal pap smears
Male Reproductive System
Rows
Never
In the past
On occasion
Often
More Info
Erectile difficulties
Skin
Rows
Never
In the past
On occasion
Often
More Info
Eczema
Psoriasis
Dryness
Bumps (on top of arms/legs)
Itchiness
Nervous System
Rows
Never
In the past
On occasion
Often
More Info
Anxiety
Depression
Heart palpitations
Low mood/flatness
Mood swings
Musculoskeletal System
Rows
Never
In the past
On occasion
Often
More Info
Joint/muscle pain
Leg cramps
Headaches
Migraines
Sleep
Rows
Never
In the past
On occasion
Often
More Info
Trouble falling asleep
Waking in the night
Waking unrefreshed
Further information you wish to share
Please describe your energy levels
Please describe your stress levels
Please describe your emotional wellbeing
Current exercise routine each week
Gym, yoga, walking, running etc
Existing allergies
In the last 12 months have you had any of these?
Laxatives
Antacids
Sleeping tablets
Anti-Inflammatories
Anti-depressants
Antibiotics
Please provide examples of each meal
Rows
Typical Meal
Breakfast
Morning tea
Lunch
Afternoon tea
Dinner
Dessert
Please complete the following:
Do you skip meals
Yes
No
Cravings
Aversions
Appetitie
Water (litres per day)
Drinks per Day
Rows
Quantity
Sugar
Milk
Tea
Coffee
Alcohol (per week)
Soft drink (per week)
Juice (per week)
Other
Please list the 3 main health goals you would like to achieve on your health journey during our time together
1
2
3
Submit
Should be Empty: