CONTACT DETAILS NUTRITION

Today’s date:

Welcome to NatMed. As part of our commitment to ensuring the best possible care for all our clients, it is recommended that you take a few minutes to complete these forms. If there is anything that you do not understand, please ask one of our staff members. The information you provide is for our records only and confidentiality is assured.

(Mr. Mrs. Miss. Ms.) First Name: Surname:

Street: Suburb Postcode

Phone: (H) (Wk) (Mob) **

**you will receive an automated text message from our diary 2 days prior to your appointment which requires a “Y” reply to confirm.

Can we confirm appointments via home line (if we do not hear back from the text message)? Yes ð No ð

Email address

Can we confirm appointments via email? (if we do not hear back from you otherwise)? Yes ð No ð

Please do not subscribe me to the e-newsletter (Tick if you do not wish to receive our e-newsletter) ð

D.O.B.: Occupation:

Emergency contact: Name: Best Contact Phone No:

Previous Doctors seen:

How did you first hear about NatMed: (please tick appropriate box and provide details where applicable)

ð Internet Search ð NatMed Website ð NatMed @ the Markets ð Natural Therapy pages

ð Referral by friend (name: ) ð Referral by Professional (name: )

ð Sign/Walk by ð Other (please provide details):

NATMED CANCELLATION POLICY

NatMed now operates with a cancellation list for appointments as we have a very high demand. This means that if you need an urgent appointment we will keep you on that list and give you the first cancellation.

In order to service all our clients better we ask that you give 48 hours notice of cancellation.

Our practitioners make sure that they are here to service their appointments and when a client does not show up or give enough notice it means that other clients miss out on the opportunity to see them.

If we receive the 48 hours notice, no fee will be charged for cancelled appointments. Failure to give appropriate notice (48 hours) results in the full consultation fee being charged.

I (your name: please print) ______agree to NatMed’s cancellation policy for appointments (above) which states that cancellation of appointments with less than 48 hours notice will be charged to me.

Signed Date

HEALTH CONCERN / HEALTH GOAL

What is the reason for your visit? What are your primary health concerns?

Who have you seen about your health concerns so far?

CURRENT MEDICATIONS AND SUPPLEMENTS

Present Medications / Supplements/ Contraception:

Drug/Supplement Name: Reason for taking: Duration and dose:

FAMILY HISTORY

Please tick if a family member has had any of the following & write the family relationship in the next column.

Who / Who
Alcoholism / Heart Disease
Allergies / Headaches
Arthritis / High Blood Pressure
Asthma / Mental Disorders
Cancer / Nervous Disorders
Diabetes / Skin Disorders
Thyroid / Other/Please specify

HEALTH APPRAISAL

PAST / RECENT
Digestion / Heartburn or reflux
Bloating after meals
Constipation
Burping or wind
Diarrhoea or loose stools
Nausea
Lungs / Asthma or Emphysema
Pneumonia or Bronchitis
Wheeze after exercise
Immune
System / Boils or pimples
Cold sores
Conjunctivitis
Ear infection
Genital infection
Mouth infection
Sinusitis
Sore throat
Thrush/Candida
Tonsillitis
Urinary infection
Skin, Hair, & Nails / Acne or pimples
Brittle nails
Dry eyes or mouth
Dry skin
Eczema or Dermatitis
Early greying of hair
Hair Loss
Psoriasis
Rashes
Sore and cracked lips
Tinea or ringworm
Stretch marks
White spots on nails
Warts
Allergies / Allergic to medication
Allergic to foods or herbs
Hay fever or sinus trouble
Nasal blockage
PAST / RECENT
Male Reproductive Health / Abnormal prostate results
Been on steroids
Erectile dysfunction
Female Reproductive Health / Thrush
Abnormal pap smears
Breast lumps or cysts
Breast tenderness
Endometriosis
Fibroids
Ovarian cysts
PMS/PMT
Urinary / Stones
Cystitis
Urine or Kidney infection
Prolapse
Liver/Gall bladder / Stones
Hepatitis or Jaundice
Liver damage or fatty liver
Abnormal liver function tests
Heart / Angina or Chest pain
Cold hands and feet
Fluid retention
Heart Attack
Heart failure
Heart murmur
High blood pressure
Palpitations/irregular heart beat
Blood Disorders / Anaemia
Iron deficiency
Easy bruising
Low white cell count
Deep vein thrombosis
Pulmonary embolus
Sleep / Disruptive sleep
Insomnia
Snoring
Unrefreshed sleep
Cancer
PAST / RECENT
Nervous system / Agitation or Anxiety
Irritability
Migraine or other headaches
Poor night vision
Dizziness or Vertigo
Facial twitching
Fits or seizures
Blurred vision
Depression
Memory loss
Chronic pain
Mood swings
Pins and needles/numbness
Chronic Fatigue syndrome
Tinnitus
Tremor of the hands
Loss of balance or poor balance
Musculo-skeletal / Muscle weakness/heaviness
Muscle or bone pain
Leg cramps
Gout
Fidgeting or restless legs
Accidents
Infections / Candida
Helicobacter infection
Glandular Fever
Leaky Gut syndrome
Mycoplasma
Oral or genital herpes
Weight / Anorexia/Bulimia
Other / Osteoarthritis
Rheumatoid arthritis
Gout
Lupus
Ankylosing spondylitis
Ross Rriver virus
Shingles
Diabetes
Thyroid problems

NUTRITION ASSESSMENT

PLEASE LIST
Food Allergies
Food Sensitivities
Restricted diet ie vegetarian, vegan, etc
Coffee / tea intake (per day)
Alcohol intake (per day)
Cigarettes (per day)
Do you grow vegetables / herbs?
Where do you buy food? ie supermarket, growers market
Do you cook your own meals?
Do you cook for others?
Do you enjoy cooking?
Do you spend much spend much time on food prep? For example: making fermented foods, broths, kefir, etc

DIET DIARY

Please include specific quantities, ie 1 Tbspn yoghurt, handful blueberries, 2 Tbspn oats, 1C milk, 1 tspn pumpkin seeds

Day One / Day Two / Day Three
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Beverage
INFORMED CONSENT & PRIVACY CLEARANCE
I (your name: please print) have been advised by my practitioner of “NatMed Natural Medicine Clinic” that he/she is not a medical doctor and that NatMed is not a medical practice. As such he/she does not practice or prescribe allopathic medicine. I understand that he/she is a Naturopath. As such he/she seeks to activate and support the self-healing mechanism of the body. He/she utilises Naturopathic Medicine i.e. Nutrition, Herbal & Homeopathic Medicines and encourages preventative health care in the form of dietary, exercise & lifestyle management.
I give NatMed permission for my health history to be kept on file for the purpose of naturopathic care planning & prescribing. I give NatMed permission to access past & current records from other health professionals I have or am seeing as appropriate. To the best of my ability all information given here is a true and accurate representation of my health.
Signed Date