New Patient Profile Questionnaire

Please complete the following items and return to the clinic prior to your initial consultation:

 

  1. New Patient Profile Questionnaire (below)
  2. Health Systems Check
  3. Food diary

 

Contact Details

Name
Email
Address
Phone
Emergency contact
Medical Contact
Do you give permission for me to contact your GP if necessary?

Personal Information

Date of Birth
Gender
Height
Weight
Have you recently gained or lost weight?

Health Concerns

What is your main health concern and reason for booking a consultation?
In brief, what treatments have your tried so far for this health problem?
Under what conditions do your current health problem get worse?
Under what conditions do your current health problem get better?
Please list any other health concerns that you would like addressed.
Please list any health problems that you have suffered from previously, but which are currently not active.
Allergies and Intolerances
Includes medications, supplements, foods, environmental triggers.
Previous surgery
Have you ever seen a Naturopath or Nutritionist before?

Family History

Please list any medical conditions experienced by family members.
Can include parents, grandparents, siblings, and other relatives where relevant.

Current Medications

Medications
Prescription drugs, over-the-counter medications, laxatives, pain killers, sleeping aids etc.
Supplements
Vitamins, minerals, herbs, nutritional preparations.

Lifestyle

Daily energy levels out of 10
0 = Unable to get out of bed to 10 = Bursting with energy.
Sleep quality out of 10
0 = Can't sleep at all to 10 = Sleep soundly every night.
If employed, what type of work do you do?
Average number of hours worked each week?

Women Only

Are you currently pregnant?
Are you planning to become pregnant?
Are you taking any hormonal birth control?

Nutritional Information

Are you vegetarian or vegan?
If yes, for how long and what type?
If vegetarian, please describe type. For example: lacto-ovo, pescatarian, vegan
Do you follow a special diet?
If yes, please describe.
E.G. gluten free, dairy free, low histamine, Paleo, low carb
How often do you buy take away or restaurant meals each week?
Indicate if breakfast, lunch, dinner or snacks.
Have you ever suffered from an eating disorder?
Daily water intake?
Number of coffees each day?
Number of teas each day?
Number of soft drinks in a day or week?
Amount of fruit juice in a day or week?
Number of alcoholic drinks in a day or week?
Do you smoke cigarettes?
Do you take recreational drugs?

And finally ...

How did you hear about me?
Blood Test Results
To attach files drag & drop here or browse file

Max file size: 1 MB. Acceptable file types:

Please upload any blood tests results conducted in the past 12 months.
7 Day Food Diary
To attach files drag and drop here or browse file

Max file size: 1 MB. Acceptable file types:

Please download and complete the '7 - Day Food Diary' form. Then attach here.
Health Systems Check
To attach files drag and drop here or browse file

Max file size: 1 MB. Acceptable file types:

Please download and complete the Health Systems Check form. Then attach here.