Patient Pre AnalysisName Number Address Email Weight Height DOB Martial Status - Select -MarriedUn MarriedAge Are you currently seeing any other health care professionals? Yes No Have you had any recent diagnoses by your GP or other health care professional? Yes NoHave you been to a Naturopath / Nutritionist / Herbalist before? Yes No Are you currently taking any pharmaceutical medications Yes NoHow do you feel today? - Select -HealthyUn HealthyTiredGoodBadNauseousAre you currently taking any pharmaceutical medications? Yes NoAre you currently taking any herbs, vitamins, minerals etc.? Yes If yes, please fill in the table. or No Yes NoHave you had any major surgeries? Yes NoHave you had any previous injuries like fractures / sprains / strains? Yes No Family medical history : Please list any major conditions / illnesses that the following people currently have or had Your medical history : Please note which illnesses you had as you were growing up? Please note your approximate age and if it is still current. If current, please note current / ongoing treatment Please mark if you have any of the following Cancer HIV / Aids Tuberculosis Diabetes Heart disease Haemophilia Thyroid problems Epilepsy Osteoporosis Arthritis / Rheumatism Metal pins / Plates PacemakerLiver/gall bladder Pale / Clay coloured stools History of jaundice History of Hepatitis A, B or C Unexplained itching Fatty foods cause indigestion and nausea Yellowish discolouration eyesImmune Colds / Flus Frequent infections Allergies / hay fever Thrush Cold soresEar, Nose, Throat Sore throat Tonsillitis Ear infections Sinusitis Tinnitus Allergies / hay feverRespiratory Emphysema Cough Pneumonia Wheezing / shortness of breath Asthma Difficulty breathing BronchitisMusculoskeletal Aches and pains Joint pain Joint swelling Muscle cramps / twitching Headaches Disc herniation / protrusions SciaticaCardiovascular High blood pressure Low blood pressure High cholesterol Arrhythmia Stroke Dizziness Chest pain Breathlessness on exertion Leg pain on exertion Palpitations Cold hands and feet Easy bruising Varicose veins Nose bleedsUrinary Frequent urination Dribbling urine after urination Strong and sudden urge to urinate Frequent bladder infections Blood in urine Pain or burning urination Getting up at night to urinate Poor urine stream Incontinence Mucous in urineSkin Acne Eczema Dermatitis Poor wound healing Dry skin DandruffUpper digestion Heartburn / acid reflux Indigestion Burping Stomach pain Sense of fullness after eating Nausea / vomitingLower digestion/bowel health Irritable bowel syndrome Crohn’s disease Ulcerative colitis Excess gas or bloating Lower abdominal pain / cramping Haemorrhoids Polyps Stools hard / dry Stools loose / watery Stools float Stools sink Blood / mucous in stools Undigested food in stools Regular laxative useEmotional state Feelings of anxiety Panic attacks Frequent sad thoughts Pessimistic / negative thoughts Feelings of guilt Difficulty concentrating Change in appetiteMetabolic Sugar cravings Weakness Fatigue Dry skin Brittle hair Weight gain Weight loss Sensitive to heat Sensitive to cold Increased thirst Anaemia Change in appetiteAre you planning to conceive within the next 12 months? - Select -YesNoAt what age did you get your first period? Do you use: - Select -PadsTamponsMoon cupsAre These: - Select -OrganicNon-OrganicReusableFor women : Indicate cycle length and duration of bleed PMS / PMT Painful periods Breast tenderness Bloating Fluid retention Irregular cycles – long or short Ovarian cysts Fibroids Endometriosis Amenorrhoea PCOS Excess facial hair / acne Vaginal discharge Blood clots in period. Please note size (eg Heavy bleeding Menopausal problems Hysterectomy Hot flushes History of miscarriage Currently pregnant Currently breastfeeding Abnormal pap smear Thrush or vaginal itching Vaginal dryness Cystitis History of STI’s Low libido Pregnant and/or breastfeedingFor men Prostate issues Low libido Pain or swelling in groin/testes History of STI’s Difficulty sustaining an erection Difficulty urinating Poor beard or hair growthDo you smoke tobacco and/or cannabis Yes NoHave you taken any other drugs (recreational or prescribed)? Yes NoDo you currently exercise? Yes NoEnergy: How do you rate your energy levels? Score out of 10 10-6 5-1Stress: How do you rate your stress levels? Score out of 10. 10-6 5-1Do you feel you are managing your stress levels ok? Yes NoDo you tend to eat or drink more when stressed? Yes NoWhat time do you typically go to sleep? How many hours do you sleep per night? Is it easy for you to get to sleep? Yes No I agree that all of the information given in this form is true and correct. I shall advise of any health changes or new information as it comes. I make a commitment to my health and wellbeing today, and understand that the more open I can be with my practitioner, the more I shall get out of this. Submit
