Initial Intake Form | VZNaturopathy

Initial Intake Form

Welcome to VZ Naturopathy. Before we can get started we need to take a full client history. Please take 15-20 minutes to fill out this form and sign and submit when you’re done.

Thank you.

First name

Last name

Birthday

Day

Month

Year

Phone

Address

Occupation

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Emergency Contact

What is the reason for your visit to Valeriya Zakharova naturopathy?

How will you know if the above is improving, and what time frame do you expect this to happen?

GPs Name

GPs Phone Number

Diagnosis (if applicable)

Have you seen a Naturopath before?

Yes

Have you used Liquid Herbal Extracts before?

Yes

Other Treatments

Please list all prescription or over the counter medication you are currently taking

Please list all herbal medicine and supplements you are currently taking

Please list all allergies you have (food, medication, environment etc)

Have you been hospitalised and/or treated for any infectious/serious conditions or surgeries? If yes, briefly explain.

Please indicate if you have a personal or family history of any of Heart Condition

Past

Current

Family

Please indicate if you have a personal or family history of any of Low Blood Pressure

Past

Current

Family

Please indicate if you have a personal or family history of any of High Blood Pressure

Past

Current

Family

Please indicate if you have a personal or family history of any of Diabetes

Past

Current

Family

Please indicate if you have a personal or family history of any of Neurological Condition

Past

Current

Family

Please indicate if you have a personal or family history of any of Spinal or Head Injury

Past

Current

Family

Please indicate if you have a personal or family history of any of Respiratory Issues

Past

Current

Family

Please indicate if you have a personal or family history of any of Kidney Disorder

Past

Current

Family

Please indicate if you have a personal or family history of any of Cancer

Past

Current

Family

Please indicate if you have a personal or family history of any of Hepatitis

Past

Current

Family

Please indicate if you have a personal or family history of any of HIV/AIDS

Past

Current

Family

Please indicate if you have a personal or family history of any of Osteoporosis

Past

Current

Family

Please indicate if you have a personal or family history of any of Headaches/Migraines

Past

Current

Family

Please indicate if you have a personal or family history of any of Sprains/strains/fractures

Past

Current

Family

Please indicate if you have a personal or family history of any of Arthritis

Past

Current

Family

Please indicate if you have a personal or family history of any of Jaw Pain

Past

Current

Family

Please indicate if you have a personal or family history of any of Dizziness/Fainting

Past

Current

Family

Please indicate if you have a personal or family history of any of Contagious Illness

Past

Current

Family

Please indicate if you have a personal or family history of any of Skin Conditions

Past

Current

Family

Please indicate if you have a personal or family history of any of Digestive Conditions

Past

Current

Family

Please indicate if you have a personal or family history of any of Lung Conditions

Past

Current

Family

Please indicate if you have a personal or family history of any Reproductive (menstrual/fertility/libido) issues?

Past

Current

Family

Please indicate if you have a personal or family history of any Mental health issues?

Past

Current

Family

Please indicate if you have a personal or family history of Wearing a Pacemaker

Past

Current

Family

Please indicate if you have any Upcoming Surgery

Yes

Do you smoke cigarettes? If so, how often?

Do you drink alcohol? If so, how often?

Do you take recreational drugs? If so, how often?

Do you drink coffee? If so, how often?

Do you drink soft drink? If so, how often?

List all current physical activities and how often you do these.

List your typical diet. What do you eat for breakfast, lunch and dinner? Do you Snack?

How much water do you drink during the day? Is it tap or filtered water?

Your weight KG

Your height CM

Up-to-date Vaccinations

Yes

None

Rate your current Energy levels out of 10 (1 is the lowest, 10 is the highest energy)

Rate your current Stress levels out of 10 (1 is the lowest, 10 is the highest stress (panic attacks)

Rate your current Quality of Sleep levels out of 10 (1 is the lowest, 10 is the highest quality, e.g.sleeping really well)

How frequent are your bowel motions? (easy to pass, undigested food, mucous?)

Please add any recent test results if applicable

File upload

Policy

It's important for me to collect your personal information before any consultation with you, so I can provide the best service at my practice.

Your personal information will be held confidentially in electronic record and in a manner that reasonably protects it from misuse and loss and from unauthorised access, modification or disclosure. Personal information will only be used for medical services and for payments, otherwise I will consult you for your consent.

Your personal information will not be disclosed with any third party without full disclosure with you. I will explain the reason beforehand, and will only share it with your consent.

There are some exceptions to disclose without your consent and that includes where I am required or authorised by law; this may include to prevent a serious threat to a patient's life or safety or to someone else's life, or if I am unable or it is impractical to obtain the patient's consent.

I will not use your personal information in any direct marketing without your consent - and you will have an option to unsubscribe at any moment. Appointment confirmations are not considered marketing communications.

Do you accept this policy?

Yes

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Day

Month

Year