Naturopathic Client Information


Step 1: Complete New Patient Form

In preparation for your initial appointment, please complete the following questionnaire. Please be assured that we respect your right to privacy, your health information and personal details are held in the strictest confidence.

The information you provide here allows us to create healthcare protocols that have been specifically designed for your individual needs, so please include as much detail as possible.

Contact Information

First Name: Surname:
Date Of Birth: Address:
Suburb: State:
Postcode: Home Phone:
Mobile: E-mail Address:
Skype Name: Occupation:
Emergency Contact Name: Emergency Contact Phone:
Relationship: Name of G.P:
GP Phone Number:

How did you hear about us? www.bondihealthandwellness.com

Bondi Health & Wellness Facebook Page

www.taniaflack.com

Magazine Article

Blog

Word of Mouth

Other


Who referred you? Doctor


Health Professional


Friend/Family/Colleague


How Can We Help You?

What are the main health problems concerning you today?
Description:
What are your top 3 health goals? (In order of priority)





On a scale of 1-10 (1 being very poor, 10 being excellent), how would you rate your current health?

Health Information

Height: cm Weight: kg Blood Group:

In a few words, please provide details on the state of your:

Gut Health:
Hormone Health:
Libido:
  
Immune System:
Allergies

Sleep
Sleep patterns Average Hours a night:
Do you wake refreshed?   

Energy Levels
Please provide details:

Stress
Please provide details:

Mood/Mental Health:
Please provide details:

Are you happy with your current weight?:
Metabolism/Weight:

Appetite:
  
Do you experience any cravings?
Food Intolerances / Sensitivities
Exercise
Current Fitness Levels:
How would you describe your usual diet?
Are you open to making changes to you diet?
  
Weekly Consumption of:
Caffeine: Alcohol:

Are you a smoker?
Amount per day? Years you have smoked When you stopped smoking

Have you ever taken recreational drugs? Please provide details

Female Clients Only

Are you
Is your cycle

Usual method of contraception:

Do you have children?
Ages
Are you Pregnant?
Number of weeks:
Are you breastfeeding?
Are you planning a pregnancy in the next 18 months?

Current Conditions

Please tick if you suffer from:

Allergies

Anaphylactic Reactions

Anxiety

Arthritis

Asthma

Autoimmune Condition

Blood Clotting Disorder

Bowel Problems

Cancer

Chronic Pain

Circulation Problems

Depression

Diabetes

Digestive Problems

Epilepsy

Fatigue

Fertility Problems

Genetic Disorder

Headache/Migraine

Heart Condition

Hepatitis/Liver Condition

High/Low Blood Pressure

HIV

Hormonal Imbalance

Kidney Condition

Lowered Immunity

Menopause

Muscular Pain

Neurological Condition

On Long Term Medication

Psychiatric Disorder

Respiratory Condition

Skin Condition

Spinal/Joint Problems

Sports/ Vehicle Accident

Surgery - Last 5 Years

Thyroid Condition

Urinary Tract Problems

Weight Problems


Please give details

Pathology - Have you recently or in the past had abnormal pathology results? Please provide details

** Please bring your most recent pathology result and any relevant medical reports with you to your initial appointment
 

Medications you are currently taking

Name Dose Reason for Taking Duration
 

Supplements you are currently taking

Name Dose Reason for Taking Duration

Personal Health History

(Past major illnesses, accidents or surgeries)

Family Health History

Please provide details of any significant family health problems
Relative Age Health problems If deceased, cause Age at death
Mother
Father
Sibling
Sibling
Sibling
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt/Uncle
Aunt/Uncle
Cousin
Cousin

Do you have any particular concerns relating to family health problems that you would like to prevent? Please provide details
 

Cancellation Fee

We require 24 hours notice if you need to cancel or change your appointment, otherwise a cancellation fee of the full cost of the appointment will apply.

Privacy Policy

We respect your right to privacy. All information you provide will be held in the strictest confidence. We will never release your health information, including pathology results, to another party without your express written consent.

Thank you! The information you supply here ensures you receive the most appropriate treatment. Your signature confirms that the information you have supplied is true and correct and that you have acknowledged and agreed to our cancellation policy.
To digitally sign this document, tick this box and enter your full name:
Digitally Signed Full Name: Date:

Step 2: Submit