Pre Consultation Health Intake Form

Personal

Medical

Allergies

Life

1. Personal & Contact Details

First Name *

Last Name *

D.O.B *

Address *

City

Postcode

Telephone (Day)

Telephone (After hours)

Mobile *

Email Address *

Emergency Contact Name

Relationship

Phone

General Practitioner

Naturopath

Marital Status

Children No.

Occupation

Blood Type

Last visit to a doctor (date + reason)

Last visit to a natural health practitioner (date + reason)

2. Presenting Concerns & Main Health Issues

What are your main health issues concerning you today? *

Previous Treatment

What major health issues have you had in the past? (With dates)

Medical History

History of Current Medical Conditions (Please tick):

High blood pressure

Diabetes

Heart disease

Stroke

Cancer

Thyroid disease

Autoimmune disease

Kidney disease

Liver disease

Lung disease

None of the above

Other

Please provide your most recent blood pressure reading (if known):

Blood pressure (mmHg):

Date taken:

Location taken (home monitor / pharmacy / GP clinic / other):

I do not know my blood pressure

I have not had it checked recently

If you have a home monitor, please take a reading before your consultation if possible.

Current Medications

Name

Dose

Freq

Date Started

Reason

Current Supplements

Name/Brand

Strength

Dose

Reason

Or just list them here:

Medication Sensitivity

Have you ever had unusual or severe reactions to medications, painkillers, anaesthetics, or antidepressants?

Yes

Past Surgical History

Date

Procedure

Reason

Findings

Surgeon

Medical tests – current and passed

(eg: Blood tests, Urinary tests, X-rays, CT and MRI scans, etc)

Pathology Reports

Do you have access to your latest (and past) pathology results from your doctor?

Yes

Do you need help getting them?

Yes

We will contact you with a consent form to request these records.

Family Medical History

Please list yourself and family members (eg: mother, father, sister, brother, grandparent, aunt, uncle) who currently has or once had a problem with the following:

Is there anything about your family's health history that concerns you, or that you would like to discuss?

Yes

List any other conditions not mentioned above:

Mood & Cognition

Do you experience any of the following regularly?

Persistent low mood or depression

Anxiety or panic attacks

Feeling overwhelmed / unable to cope

Obsessive or repetitive thoughts

Mood swings or irritability

Loss of interest in things usually enjoy

Difficulty with attention or focus

Poor memory or “brain fog”

Sleep difficulties

Fatigue or low motivation despite rest

Suicidal thoughts

Social withdrawal or avoiding interactions

Energy & Stamina

On a typical day, how would you rate your overall energy level? (1 = exhausted, 10 = excellent energy)

Do you feel you would benefit from having more energy?

Yes

If yes, when do you feel most fatigued? (morning / afternoon / evening / all day):

What seems to worsen your fatigue? (stress, poor sleep, exertion, after meals, illness, unknown, etc):

Allergies and Intolerances (please indicate)

Dairy products

Soy products

Yeast

Wheat

Gluten

Starch

Sugar

Tomatoes

Artificial flavours

Colourings

Alcohol

Metal jewellery

Bandaids

Cleaning products

Dust mites

Grasses

Pollens

Fur

Other

Please specify other allergies:

Reactivity Screening

Do you notice strong reactions to any of the following?

Sulfur-containing foods (garlic, onions, eggs, broccoli, cauliflower, cabbage)

Histamine-rich foods (wine, cheese, fermented foods, sauerkraut, vinegar, etc)

Do you react to high oxalate foods (spinach, almonds, almond milk, dark chocolate, cocoa, sweet potato, beets, rhubarb)

Alcohol (flushing, headache, nausea from small amounts)

Vitamin supplements (especially B6 or folate)

What kind of reaction occurs? Please explain:

Environmental & Detoxification Sensitivities

Do you notice strong reactions to any of the following? (tick all that apply):

Perfumes / fragrances

Cleaning products

Paints or solvents

Cigarette smoke

Pesticides or herbicides

Mould exposure

Other (please specify)

Detoxification Questions

Do you experience symptoms from everyday chemicals (e.g., perfumes, cleaning agents, petrol fumes)?

Yes

Please describe symptoms:

Do you tolerate caffeine well?

Yes

Gut History

Do you regularly experience:

Bloating

Reflux / Heartburn

Diarrhoea

Constipation

Food Intolerances

Lifestyle & Environment

How would you describe your work/life balance?

Balanced

Sometimes stressful

Very stressful

How often do you exercise or move your body?

Daily

A few times per week

Occasionally

Rarely / Never

How many hours of sleep do you get on average per night?

hours

Do you currently smoke?

Yes

How many alcoholic drinks do you consume per week (on average)?

drinks

How many cups of coffee, tea, or caffeinated drinks do you consume daily?

cups

How many glasses of water do you drink daily (approx.)?

glasses

Do you use recreational drugs?

Yes

Stress & Wellbeing – On a scale of 1–10, how stressful do you feel your life is right now? (1 = calm, 10 = highly stressful)

Do you have regular relaxation practices (e.g., meditation, yoga, breathing, hobbies)?

Yes

Almost there - Promise!

Just one final section: a quick look at what you typically eat and drink each day. This helps us personalise your recommendations.

Average Daily Diet

Please provide details of an average day's diet (or what you had yesterday). Include beverages, snack food, use of diet products, artificial sweeteners, cooking style, restaurant food and junk food.

Breakfast

Time

Morning Tea

Time

Lunch

Time

Afternoon Tea

Time

Dinner

Time

Supper

Time

Snacks or sweets not covered previously

Eating out

Beverage intake

Please include details on normal daily consumption of fluids. These include water, soft drinks, cordials, juice, alcoholic drinks, coffee, tea, herbal teas and coffee substitutes. Indicate how you have your coffee/tea e.g. one/two sugars? White? Full cream milk? etc

Final Details

Anything else you'd like me to know before your consultation?

Upload any relevant files

Test results, records, scans, etc.

Review Your Details

Please review the information below. If everything is correct, click "Confirm & Submit". Otherwise, click "Edit" to make changes.