New Patient online Questionnaire

Surname*:

Given Names*:

Date of Birth*:

Age*:

Sex*:

MaleFemale

Address*:

Suburb*:

Post Code*:

Phone:

Bus:

Mobile*:

Email*:

Best contact for confirmation of appointments:

TextCallEmail

Marital Satus:

SingleDefactoMarriedDivorcedWidow

Children?

YesNo

If so how many?

Occupation:

How long have you done this job?

How did you hear about the clinic/who where you referred by?

Who is your family GP?

Do you see any other health practitioners?: (chiropractor, Specialists etc):

Have you ever consulted with a Naturopath or Natural Medicine Practitioner before?, if so when?

Are you in a health fund if so which one which cover for Natural medicine?

Are you Currently on Medication if so what type?

Do you take supplements? (vitamins, herbs etc)

Do you have any known Allergies?

YesNo

What type?

Why are you here today?

How long have you had this problem?

What makes symptoms better or worse?

When did you last feel well?

Do you have any surgical scars?

YesNo

If so where?

Have you recently had any major changes in your life? ie (move house, divorce etc)

Do you have any problems in any of the following areas? (please select)

HeadEyesEarsNoseMouthThroatChest & Respiratory ChestCardiacCirculation problemsMusclesJointsSpineReproductive organMenstruationUrinary bladderNeurological (nerve) digestionBowelGallbladderKidneysLiver

Have you had any of the following diseases diagnosed? (please select)

DiabetesCancerHeart diseaseArthritisHigh /low blood pressureHIV AIDSOr other please specify

What do you normally eat?

Breakfast:

Morning tea:

Lunch:

Afternoon tea:

Dinner:

How Much Water do you drink?

Tea or coffee?

YesNo

How much?

Do you use recreational drugs/alcohol, cigarettes?

Do you exercise?

YesNo

Please specify what type how often?

How much stress do you have? Scale of 1-10

Do you sleep well?

How many hours?

How is your energy? Scale of 1-10

What is your blood type?

Secretor status:

Signature:Use your touch screen or mouse to sign

Date:

Print name:

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