Naturopath Client Registration Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of Birth *Gender *Relationship Status *Contact Number *Emergency Contact (name, number and relationship to you) *GP/Medical Centre Contact *Permission to contact if necessaryYesNoOccupation & time in current employment *Previous occupations & time in employment *Number of children and ages *Do you have any religious or cultural considerations? *Please provide a brief outline of why you are seeking treatment: *Has this been diagnosed? If yes, by whom, when and what was the diagnosis? *Have you sought advice or treatment for this through other means? *List any medications and supplements that you currently take: E.g. BP, inhalers, antibiotics, pain, sleep, anti-depressants, laxatives, antacids, contraception (OCP, Mirena, rods, injection), vitamins, minerals etc. Include brand names, frequency, dose, strength and how long you have been taking them for. *List any family history of disease from both maternal and paternal sides, including siblings and children's current and previous illnesses. *Outline your personal health history, including childhood diseases, accidents, injuries, operations, past medications, hospitalisations, allergies, your birth (type, interventions, breastfed) and your mothers health during her pregnancy with you. *Provide details of significant emotional events in your life from childhood to now. Give the age you were, the type of event and the impact that it had on you. *Your current health – tick all that apply – Digestive HealthConstipation/diarrhoeaHeartburn/refluxIBD – Crohn’s/ulcerative colitisIrritable bowel syndromeCoeliac diseaseOtherEndocrine SystemDiabetes/prediabetesThyroid imbalancesRecent weight loss/weight gainAdrenal fatigue/Cushing syndromeOtherIntegumentary SystemEczema/dermatitisPsoriasisInflammatory skin conditionsAcneRecurring rashes/itchingHivesOtherRespiratory SystemAsthmaShortness of breathPneumoniaExcess mucus/phlegmPersistent/frequent coughSinus problemsOtherLymphatic/Immune SystemGlandular feverSwollen glandsAllergiesFrequent/reoccurring infectionsAutoimmune conditionsPost viral syndromeCancerOtherCardiovascular SystemHigh or low blood pressureHigh cholesterolStroke/heart attack/anginaAnaemia/iron deficiencyChest pain/heart palpitationsVaricose veinsOtherMusculoskeletal SystemRheumatoid arthritis/osteoarthritisJoint pain/stiffnessMuscle pain/recurrent crampsChronic injuriesGoutOtherUrinary SystemFrequent urinary tract infectionsKidney disease/kidney stonesIncontinencePainful/excessive urinationNight time urination (nocturia)OtherReproductive System (women)Premenstrual syndrome (PMS)EndometriosisPCOSAbnormal cervical smearReoccurring thrushSexually transmitted diseaseFertility issues/concernsOtherReproductive System (men)Sexual dysfunctionProstate enlargementSexually transmitted diseaseFertility issues/concernsOtherNervous SystemDepressionAnxietyHeadaches/migrainesSleep difficulties/insomniaMemory lossEpilepsy/seizuresOtherSensesImpaired eyesightBlurred visionHearing lossRinging in earsPoor sense of tastePoor sense of smellOtherIf you selected 'other' for any of the above answers, please explain in further detail below:How motivated are you to make changes to your health? (0 – none, 10 – I'll do anything it takes) Selected Value: 0 What would you like to achieve as a result of seeing me? *Submit
