Initial patient intake form

Wellness by K

Naturopathy/Nutrition consultations
Consultations by Kris Jasper

BHSc - Naturopathy
CLIENT/PATIENT CONFIDENTIAL INTAKE FORM
Name*

First NameLast Name
Date of Birth*
Age*
Gender or Sexuality
Address*

Street Address

Street Address Line 2

CityState

PostcodeCountry
Phone Number*

Area CodePhone Number
Email*
example@example.com
Emergency contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
General Practitioner

First NameLast Name
General Practitioner Phone Number

Area CodePhone Number
What is your main reason for visiting the naturopath/nutritionist today?*
Please list diagnosed medical conditions: *
Please list medications, natural remedies or over the counter medicines with dosages and brands (if known) you are currently taking:*
Are you pregnant or is there a possibly you could be pregnant?*
Please list any allergies or intolerances known (including food):*
Do you a family history of:*

AlcoholismArthritisAutoimmune condition (State which in other)AsthmaAnxietyCancerCoeliac DiseaseCrohn's disease/ Ulcerative colitisDepressionDiabetes (type 1 or 2)EczemaEhlers-Danlos Syndrome (state which type in other)Heart disease/conditionsHypertensionHypotensionHypothyroidism/ Hashimotos thyroiditisHyperthyroidism/ Graves DiseasePOTS (please state type in other)Other
Is there any additional information you wish to add?
How did you discover Wellness By K *
Privacy Policy:

When attending this clinic it is on the understanding the form of care is in line with the principles of Naturopathy/Nutrition including herbal medicine, nutritional medicine and diet and lifestyle advice. This practitioner will not modify or prescribe allopathic medicine protocols.

It is understood even the gentlest of treatments can present complications in certain physiological conditions, very young children and those taking multiple medications. Therefore, it is essential the information provided by you is complete, accurate and inclusive of all health concerns; including risk of pregnancy and all medications, natural medicines and over the counter pharmaceuticals.

Test results ma be requested by your practitioner to provide further information about you and your condition and a copy of these results will be kept in your confidential file. At all times your privacy and any information collected will be treated confidentially and discreetly. This privacy policy complies with the National Privacy Principles contained within the Privacy Act 1999 and the amendments made by the privacy amendments (Private Sector) Act 2000.
Informed Consent:

I have read and understood the above information and I accept full responsibility for any fees incured during care and treatment.
Full Name*

First NameLast Name
Date*
Signature*

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Wellness by K