In Clinic Booking – Initial Consultation

First Name*

Last Name*

Email Address*

Phone Number*

Date of Birth*

Occupation*

Postal Address*

Suburb*

State/Postcode*

Have you seen a Naturopath before today?* Have you seen a Naturopath before today?* YES NO

What are your health concerns?*

When noticed and how long for?*

Previous/current treatments?* Previous/current treatments?* YES NO

Currently under care of a physician or other health care professional?* Currently under care of a physician or other health care professional?* YES NO

If yes please provide last visit & type of health professional:

What is your blood type?*

Have you got any known allergies?* Have you got any known allergies?* YES NO

Reactions please describe for any allergies (eg itching redness shortness of breath)*

Do you smoke?* Do you smoke?* YES NO

If yes how many?

Do you drink alcohol?* Do you drink alcohol?* YES NO

If so how much?

Do you take recreational drugs?* Do you take recreational drugs?* YES NO

Family medical history (please list conditions and major illnesses)*

List medications/ nutritional supplements currently taking:*

Do you exercise?* Do you exercise?* YES NO

How regular?*

How long for ?

Add any extra information not asked above about you?*

Statement of Acknowledgement : I ask for your cooperation in signing this statement of acknowledgement. (please tick each box) Statement of Acknowledgement : I ask for your cooperation in signing this statement of acknowledgement. (please tick each box) I understand Naturopathic Doctors ND are not Medical Doctors; we use non- invasive, natural methods in assessing you for treatment of body dysfunctions. I understand the treatment and or referral to other health practitioners is based upon the assessment of your health through your personal history, tests and other necessary methods of evaluation. I understand the complete responsibility for your health care is your own and I will be supportive of this. I do reserve the right to discontinue my services where your expectations and what I provide are not in agreement. I understand that a record will be kept of health services provided to me. These records will be kept in confidence and not released to others unless you give your consent or the law requires it. I understand my Naturopath will answer questions to the best of her ability and understand that results are not guaranteed. I do not expect my Naturopath to be able to anticipate all complications and risks for example allergic reactions to herbs and supplements. I will rely on my Naturopath to express judgment during the course of the treatment plan which they feel at the time is in my best interests based on the health facts then known. I understand this consent form covers my whole course of treatment under my Naturopath practitioner. I understand I am free to withdraw my consent and discontinue participation in treatment at anytime. By typing name below and clicking submit I agree that I have read completely and understood the above information.

Full Name (in acceptance of the above statement of acknowledgement)*