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Online Health Form

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Name*
First Last
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Age*
Nationality
Occupation
Hours per week
Address*
Address City State/ Provice Zip / Postal Code Country
Phone Number*
Mobile Number
Email Address*
How do you hear about us?*

EMERGENCY CONTACT
Name
Mobile Phone
Relationship to client
DOCTORS DETAILS
Family Doctor
Family Doctor's Address
Doctor's Phone
Phone

PERSONAL MEDICAL HISTORY
What are your main health issues concerning you today? (list in order of importance)
1 What are your main health issues concerning you today? (list in order of importance)
2 What are your main health issues concerning you today? (list in order of importance) 2
3 What are your main health issues concerning you today? (list in order of importance) 3
How long has your main concern been bothering you?
is there anything that could have caused this or be contributing to it?
What treatment approaches have you tried?
1 What treatment approaches have you tried?
What treatment approaches have you tried?
What treatment approaches have you tried?
Have you ever seen a Naturopath before?
- Yes
- No
If 'Yes', when?
What were the results?
Are you currently seeking treatment from a Doctor/Specialist?
- Yes
- No
If 'Yes' who?
Please indicate if you have any known allergies (tick which apply)
- Dairy products
- Soy products
- Yeast
- Wheat
- Gluten
- Starch
- Sugars
- Tomatoes
- Artificial Flavours
- Colourings
- Alcohol
- Metal Jewellery
- Band aids
- Cleaning Products
- Cigarette Smoke
- Dust mites
- Medicines
- Grasses
- Pollens
- Fur/ Dander
- Other

Type of

Medication/Supplement	Brand	Dosage per day	Approximate time of Commencement

Click the plus(+) symbol to add more information

FAMILY HISTORY
High Blood Pressure
- Yes
- No
High Blood Pressure Relative/s
Arthritis
- Yes
- No
Arthritis Relative/s
Thyroid Problems
- Yes
- No
Thyroid Problems Relative/s
Heart Disease
- Yes
- No
Heart Disease Relative/s
Mental Illness
- Yes
- No
Mental Illness Relative/s
Kidney Disease
- Yes
- No
Kidney Disease Relative/s
Diabetes
- Yes
- No
Diabetes Relative/s
Depression
- Yes
- No
Depression Relative/s
Liver Disease
- Yes
- No
Liver Disease Relative/s
Respiratory Conditions
- Yes
- No
Respiratory Conditions Relative/s
Allergies
- Yes
- No
Allergies Relative/s

GENERAL INFORMATION
Height (cm)
Weight (kg)
Ideal Weight (kg)
GENERAL LIFESTYLE QUESTIONS
Do you smoke tobacco? If so, how many cigarettes per day?
How many glasses of water you you drink per day?
Coffee? if yes, cups per day and specific if mixed with milk and/or sugar/s?
Do you drink Alcohol? if so, how many drinks per day and specify type of alcohol.
If you drink other beverages please specify and how many glasses a day (juices, cordials, soft drinks, herbal teas)
Do you exercise? if so, how many times a week?
DIET INFORMATION
Please provide details on an average daily diet for you. In the spaces provided, please list three typical choices you would have for each meal/snack on any given day.
Breakfast
1 Breakfast
2. Breakfast
3 Breakfast
Lunch
1 Lunch
2. Lunch
3 Lunch
Dinner
1 Dinner
2 Dinner
3 Dinner
Snacks
1 Snacks
2 Snacks
3 Snacks

COVID Information
As your health practitioner, I need to prescribe treatment safely and avoid any negative interactions alongside pharmaceuticals.
Have you taken the COVID vaccine?
- Yes
- No, but planning to get it
- No
When did you receive your last vaccine?
MM slash DD slash YYYY
When do you plan to get your next vaccine? (approximate date is fine)
MM slash DD slash YYYY
Cancellation Policy*
I have had the opportunity to read and discuss all of the above, and I fully understand all of its meaning and its terms.
Thank you in advance for observing Invigorate Naturopathy's 24 hour cancellation policy. If you need to reschedule or cancel your appointment please change online, email or text Invigorate Naturopathy on 0433848828 24 hours in advance of your scheduled appointment. If you are unable to provide 24 hours' notice for the scheduled appointment you will be responsible for the full charge of the session.
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Naturopath | Invigorate Naturopathy

At Invigorate Naturopathy, clients are shown just how easy it is to reduce stress and anxiety and how to improve sleep and energy through an affordable tailor made
treatment.

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