• New Patient Intake Form

    Thanks for booking with me at nourishe health & wellness. I'm looking forward to meeting with you soon.

    This form should take you no more than 10-20 minutes to complete. You willl need to complete it in one go.

    Don't ponder the questions or answers for too long - remember this is a SYMPTOMATIC screening tool and we will discuss it in detail at your consult.

    Your answers to this questionnaire will help me address your main health concern.

    Select the option which best describes the frequency or severity of your symptoms over the last 3 months, or answer the yes or no questions by selecting the best answer.

    Some questions may be repeated throughout the questionnaire. Don't worry if you give a different answer to each one!

    All details remain confidential.

    Feel free to email me if you have any issues with this questionnaire.

    I'm looking forward to meeting with you in clinic soon.

    ALL consults require a deposit to secure your booking. 

    If you're using a voucher you will need to enter your Voucher number as follows:
    V followed by your voucher number eg V12345.
    If this doesn't work (some older vouchers may not be entered in the system) please email me.

    email Deborah here

     

  • Todays Date
     / /
    2 digit day, 2 digit month, 4 digit year
  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  -
  • I'd like to send you an email occasionally, and I need your ok to do so!*
  • Please Choose either CONSULT or WELLNESS CHECK*

  • CONSULT

    Please answer the following questions to the best of your ability.
  • Within the last 3-6 months have you (please tick any that apply):

  • Please give me some detailed information on any supplements (self-prescribed or other) you are currently taking. Also details of any Prescription (or other) medication(s) you are currently on. If you need more room to clarify please comment below.

  • Nutritional Supplements
    Rows
  • Which of the following have you taken within the last 6 months
    Rows
  • Other Medication (Prescription or Over the Counter)
    Rows
  • NUTRITIONAL SPECIFICS - please select any that apply*
  • EXERCISE*
  • I gather as much information as possible from you in order to develop what I believe to be the best plan for your specific needs. Often this involves you committing to making changes over a period of time. Please select the answer that BEST suits where you're at right now.*

  • Informed Consent:

    I understand that I will be fully informed about my treatment and any possible side-effects, and have all my questions answered to my satisfaction.  I consent to a physical assessment (if needed) and treatment plan as explained to me by Deborah Wright (practitioner).

    I understand that if I am unhappy with the treatment provided I can in the first instance address this with Deborah Wright (practitioner).

    Alternatively I can contact an independent Health and Disability Advocate by phoning (04) 494 7900.

    By submitting this form you agree to the above statement.

  • I have read & agree with the above INFORMED CONSENT. 
    *   *   

  • WELLNESS CHECK

    Please answer the following questions to the best of your ability.
  • Within the last 3-6 months have you (please tick any that apply):

  • EXERCISE*
  • NUTRITIONAL SPECIFICS - please select any that apply*
  • Nutritional Supplements
    Rows
  • Other Medication (Prescription or Over the Counter)
    Rows
  • DIGESTIVE*
    Rows
  • ENDOCRINE *
    Rows
  • IMMUNE *
    Rows
  • Do you react to or have an allergy to:*
    Rows
  • Do you consume any of the following:*
    Rows

  • Informed Consent:

    I understand that I will be fully informed about my treatment and any possible side-effects, and have all my questions answered to my satisfaction.  I consent to a physical assessment (if needed) and treatment plan as explained to me by Deborah Wright (practitioner).

    I understand that if I am unhappy with the treatment provided I can in the first instance address this with Deborah Wright (practitioner).

    Alternatively I can contact an independent Health and Disability Advocate by phoning (04) 494 7900.

    By submitting this form you agree to the above statement.

  • DISCLAIMER:

    Live Blood Screening is NOT a Diagnostic Tool.

    Your screening will show what your Red Blood Cells look like, and I will make observations based on their size, shape & activity on screen.

    I cannot and will not diagnose any medical condition, nor will I use this as a basis for any treatment options.

    I will use any images &/or video taken at the time of your screening to make any relevant lifestyle and nutritional that I feel may help your general health & wellbeing.

  • I have read & agree with the above INFORMED CONSENT. 
    *   *   

  • Payment is required to secure your booking.
    Thank You.

  • Please choose your option:*

    prevnext( X )
    CONSULT (deposit only). nourishe health & wellness now requires a deposit to secure your appointment. This is deposit is non-refundable. Should you need to reschedule, please give a minimum of 48 hours notice.

    Wellness Check (pay in full). Please note this is a non-refundable payment. You can reschedule with a minimum of 48 hours notice at no additional charge.


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