Naturopathy Intake form
Kay Ritson, Naturopath at Harmony Centre for Natural Therapies, 10/65-67 Old Logan Road, Gailes Qld Phone: 07 3879 4694
General Information
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E-mail
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Gender
Height
Weight
How did you hear about us?
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Existing Client
Google
Yellow Pages
Website
Friend
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Flyer
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Medical History
Are you under the care of any other health care providers? If so please list and give the reason.
What medications, supplements and over the counter items do you take regularly or are currently prescribed:
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Any past surgeries and hospitalizations? Please give details and dates.
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Personal History
What are your main interests and hobbies?
What is your line of work or study?
Do you exercise regularly? Please detail.
What kind of other movement or activities do you enjoy?
You have problems falling or staying asleep?
How many hours do you sleep?
Do you wake up refreshed?
Rate your energy levels on a scale of 1 - 10
Does your energy level affect your daily activities?
How would describe your mood, generally:
Does your mood affect your life or daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
Do you have people close to you who support you?
Diet and lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Please Select
Yes, 1+ pack per day
Yes, 1/2 pack per day
Yes, less than 1/2 pack per day
I have quit
I have never regularly smoked
Do you use recreational drugs
No
Yes
I did in the past
How is your appetite?
How many meals per day do you eat?
What is a typical day, in terms of food intake? Please list all meals and snacks.
How many glasses of water do you drink each day?
Please list all other types of beverages you regularly drink.
Please list any food allergies, intolerances or foods you avoid and the reason.
What past struggles and difficulties have you experienced in terms of food and dieting?
What types of diet and exercise approaches have worked for you in the past?
And what hasn't worked for you at all?
Health History
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No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depression
Anxiety
Mood swings
Nervousness
Addictions
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Dizziness
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Shortness of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Belching/gas
Constipation
Diarrhea
Please describe any major health issues experienced by your parents, e.g Heart issues, Diabetes, Stroke, cancer etc
Please tell me your main reason for coming to see me
Terms and Conditions
Cancellation or non attendance without 24 hours notice may incur a cancellation fee equivalent to the service fee.
Case notes remain the property of the Harmony Centre for Natural Therapies.
Clients may have access to their case notes on application in writing, accompanied by a copy of appropriate identification.
Any examination or treatment is on the basis of informed consent.
All case notes remain confidential unless required to be disclosed for legal reasons, or permission to share them with another person is given by the client.
Please sign in the box below. to consent to treatment and to accept the Terms and conditions above.
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