Client Intake Form

NEW CLIENT INTAKE FORM

An intake form is a very important part of your appointment, it increases the success of the consultation by directing me to the issues that need clarification when we meet along with an overview of your current health. Please take your time filling out information.

Your Name

Date Of Birth

Gender

Address

Suburb

Postcode

Email Address

Phone Number

Occupation

Weight

Height

Name Of GP and Location of Practice

Referral (Google, Friend, Etc)

Presenting Health Complaint/Goals (Please list symptoms, including any diagnosis from other practitioners and who you have seen for this condition).

Childhood Medical History:

Family Medical History

Hospitalization History

Dental History - Do you have any amalgam Fillings?

Current medications and supplements?

Allergies / Intolerances to medicines or supplements?

Please upload any relevant medical reports or test results here.

Do you follow a specific diet/eating pattern?

Do you exercise?

How much water do you drink daily?

How much coffee do you drink daily?

How often do you consume alcohol?

Do you smoke?

What are the major causes of stress in your life?

How do you cope with stress/relax/take timeout?

Please complete a 3 day food diary of what you have eaten for 3 average days - 2 weekdays and 1 weekend day.

Have you ever had significant exposure to chemicals, mould/water damaged buildings at work or at home?

Do you have any further information you would like to share?

Your email will be added to my client-only email for clinic updates, news , blog & research articles and other relevant to your treatment.

CLIENT INTAKE FORM

NEW CLIENT INTAKE FORM

Copyright 2022 | Diana Robson Naturopathy - All Rights Reserved | Privacy Policy | Website Designed By Local Edge Marketing