First Name: ---------------------Last Name:
------

E-mail address:


Date of Birth:-- ---
Height:------- -- ---
Weight:---------

Medical Background.

Have you seen a naturopath before?

Yes
No

If Yes, When and what was the reason:

Case History -
Past operations, conditions, previous medications:


Present Symptoms - Current medical conditions or complaints:


Current Medication:


Current Supplements and Herbs:


Typical Diet -
Describe the type of meals and what you have between meals.

Morning:


Afternoon:


Night:


Liquids per day (Glasses/Cups):

Water:- -
Juice:- -
Tea:- -
Coffee:- -
Soft drink:- -
Beer/Spirits/Wine:- -

Other:-

General

Any Allergies:

Do you smoke?

Yes
No

Weight loss/gain (in the last 12 months):


Energy levels
(In general, from 1-10 where 1=Fatigued 10=Energised):


Sleep
(Is it regular, interrupted,too short):


Exercise
(What type and how often):


Family Medical History

Maternal

Mother:

Grandmother:

Grandfather:

Paternal

Father:

Grandmother:

Grandfather:

Other

Anything else not covered: