New Patient Form - Female

 

 
Contact number, Relationship to you
Childhood/Adolescence
Please list below any known family medical history
eg. alcohol/drug abuse, mental illness, stroke, high blood pressure, cancer, infertility, autoimmune conditions, diabetes, allergies etc.
Vitality
What are your energy levels out of 10
Please list your top 3 current causes of stress eg. work, relationships, time poor, financial stress, physical health, emotional etc.
Who or what in your life provides you with physical/emotional support? Spouse, Family, Friends, God/Religion, Pets, Counsellor, Other?
Lifestyle
Dietary
Do you/have you followed a dietary plan based on any of the following principles: DASH, Mediterranean, Paleo, Gluten Free, Casein Free, Dairy Free, GAPS, FODMAPS, Specific Carbohydrate, Low Allergenic/Elimination, High Protein/Low Carb, Ketogenic, High Carb/Low Fat, Low GI, Caloric restriction (please describe)
Weight management
Motivation
Average Daily Diet
Please provide details of an “average” day’s diet (or what you had yesterday).
Please include details on normal daily consumption of coffee, tea, herbal teas and coffee substitutes and the number of sugars used, soft drinks, cordials, juice, water and alcoholic drinks.
Heath Appraisal
Stomach: hypoacidity
Stomach: hyperacidity
Large Intestine/colon
Pancreas/Small Intestine
Liver/Gall bladder/Pancreas
Endocrine: Underactive Thyroid
Endocrine: Overactive Thyroid
Adrenal Function
Immune Function
Allergy
RBC function, Anaemia risk
Blood Pressure
Heart
Circulation
Glucose tolerance
Kidney/Bladder
Bone
Muscle
Connective tissue/joints
Learning and concentration
Neurological
Sleep, Insomnia risk
Respiratory
Skin
Detoxification Capacity
Female Health
Premenstrual Symptoms occurring in the 14 days prior to menstruation
Menstruation (Periods)
Menopausal symptoms
Treatment consent
Confidentiality. A health professional may only provide information to another person for reasons of significant public interest or when required by legislation. New Life Natural Medicine is a Child Safe Environment in accordance with the Children’s Protection Act 1993. There are occasions where a case discussion of your de-identified case details between professional practitioners may improve the quality of care provided to you.
 Privacy. Only relevant personal information will be collected and this information will only be shared with your consent or to comply with regulatory and legal requirements such as court orders. Your personal information may be used to: provide quality health care and follow up; maintain contact with you and to provide clinic information; communicate with your other healthcare providers under a shared care model; complete private health insurance claims; invoice you for goods and services and process credit card and EFTPOS payments. 
Scope of Practice. Naturopath’s are not primary care doctors and the treatment provided is not intended to supersede recommendations or treatment provided by other registered health care professionals. Your Naturopath seeks to work in a shared care model to complement your existing healthcare. Naturopathic treatment may include natural medicine such as herbal medicines, nutritional medicines, dietary and lifestyle advice.
 Treating Infertility. Current guidelines for health care practitioners in the treatment of infertility or sub-fertility are ethically responsible to ensure that both partners that are trying to conceive are at the very least initially assessed and treatment if indicated is offered and encourage for both partners. When sub-fertility or infertility are the primary concern, your naturopath will seek to assess and if indicated, treat both partners that are trying to conceive. Your obligations. Please ensure your Naturopath is aware of all medications taken and therapies you are receiving to identify and avoid potential adverse interactions. Female patients must advise your Naturopath if you are pregnant, trying to conceive or lactating as some treatments may be contraindicated in those circumstances. Some natural medicines may contain alcohol, dairy or animal products. Please advise your Naturopath if you have religious/other reasons to avoid these substances. 
Adverse reactions. In some circumstances Natural medicines may cause unforeseen adverse reactions or allergic reactions to herbal medicines or nutritional supplements. Should you experience an adverse reaction please contact your Naturopath. In the case of an emergency, contact 000 or proceed to the Emergency Department at your nearest hospital.
 Cancellation Policy. Please give your Naturopath at least 24 hours notice if you can no longer keep your appointment time. In the event of an unforeseen circumstance preventing you from attending your appointment on the day, please be so kind to phone or email the clinic at your earliest availability to inform your Naturopath of your wellness and/or safety and to reschedule your appointment time.
Microbiota
(If under 18 years, parent or guardian to sign)
Survey
Survey
Option One
Option Two