Name

Date Of Birth

Age

Postal Address

Email

Gender

Are You?

Do you have children? If so, what ages? & is there anything that is important to note health wise, from your pregnancy, birth or postpartum journey?

Are there any comments you would like to add about your relationship and how you are feeling? eg. supported, lonely, angry, resentment, content, bored, unheard, hurt 

Have you previously experienced any terminations, miscarriages, stillbirths, or other complications? If so, when?  

Why have you arranged this Naturopath session? Give me an overall summary of how I can support you 

When did any of your current presenting health issues/ challenges begin? eg.  travelling overseas, food poisoning bout 

What, if anything have you previously tried to meet your goal/ overcome your challenge? eg. specific treatments, diet changes, lifestyle adjustments  

Do you have any previous or current diagnosed medical conditions? For each, tell me how long you had been experiencing symptoms, when were you diagnosed and what treatment has been given, if any, so far. 

Please list the year and details of any past blood tests, ultrasounds, X-rays, MRIs or operations that you can remember. 

Are you currently taking any prescribed or over-the-counter medication? Please list the name, strength, what time they are taken and how long you have been taking them for: 

Please list any natural health supplements (brand, name and dosage) you are currently taking: 

Are there times that you feel: 

What are your main feelings (above)?

Are you feeling this way at a certain time of the month, such as pre period, or after certain triggers, such as diet or alcohol? 

Do you struggle with brain fog? If so, since when? 

Describe your stress levels. What are the triggers to your stress level increasing? 

Do you struggle with memory loss? If so, short or long term and since when?  

Now for the energy chat. How would you describe your physical and mental energy in the morning, lunch, mid-afternoon and night?  

Let’s be honest…do you require stimulants to get through your day? If so, what and when? Eg. coffee, sugar, chocolate 

How many hours’ sleep do you average per night?

How long does it take you on average, to get to sleep at night?

Do you wake throughout the night? If so, when and how long are you awake for? 

Now for the toilet chat. How often do you have a bowel movement?  

Do you experience any of the following? (List below) bloating, abdominal pains, heart burn/ reflux, foul smelling flatulence, diarrhoea, constipation 

When did this become an issue for you? Do you know any triggers? 

Have you ever suffered from travellers’ diarrhoea?  If so when, what treatment did you receive and have you had any follow up testing? 

Have you had any stool or food intolerance testing performed previously? If so, when and what did the results show?  

Do you experience any muscles, spasms, twitches or cramps in any muscles? If so where and how often? 

Do you suffer from regular headaches or migraines? If so, tell me about your symptoms, how regular they occur and any known triggers. 

Do you have any joint pain? If so, where, how often and when did this begin? 

Your environment plays an important role in shaping your health. Let’s take a look. 

Where did you grow up?  

As far as you’re aware, please list any exposures to any heavy metals, toxins or mould throughout your childhood? eg. mining community, farming chemicals, spraying around your home, mould exposures 

Is your current home near any main roads, golf courses, or air traffic? 

Describe your current daily roles & any exposures to pollution, chemicals, heavy metals, welding, or radiation: 

Please list any other jobs & dates you have worked in the past: 

Do you use any weed control chemicals or fertilisers around your home?

Is your home treated for pests? 

Do you use any insect sprays in and around your home? 

Do you use fragrances in your home, car or work? (smelly tree, fragrance candles, fragrance sprays) 

Is your home a new build (last 2 years) 

Have you renovated or painted your home in the past 2 years? 

How many mins/ hours of screen time (TV, Computer, Phone) do you spend per day?  

What time of day is this screen time?

Where do you store your phone for majority of the day? (pocket, handbag) 

How many minutes/ hours are you exposed to wi-fi per day? 

How often do you fly interstate and overseas per year? 

Do you live near any high voltage power lines, or a mobile phone tower? 

What products do you use for cleaning your home? 

What products do you use on your skin? (cleanser, moisturiser, make-up) 

What toothpaste and deodorant do you use? 

What products do you use in your hair? (colour, shampoo, conditioner, products) 

Do you often wear perfume?

Do You Wear nail Polish?

What are your hobbies? 

If applicable, at what age did you first get your period? Describe your history of cycles (cycle length, pre period symptoms, period pain, heaviness, presence of clotting and length of bleeds) 

Describe your current cycle length, pre period symptoms, period pain, heaviness, presence of clotting and length of bleeds? Otherwise length of time since last period (with peri-menopause/ menopause) 

Have you been on synthetic hormones in the past and/ or currently? If so, please list the reason, type, and length of treatment.  Eg. Mirena, Oral contraceptive Pill, HRT 

List any other hormone related symptoms you are experiencing, such as skin breakouts, hot flushes, cold hands and feet, hair loss, infertility and weight challenges: 

Please include any additional information & dates you feel is important for me to know concerning your health (past and present health conditions, infections and symptoms): 

How do you include intentional movement into your day? If so, for how long? 

Do you meditate or have some form of mindful practise in your day? If so, what is it? 

If you have previously seen a Naturopath, please indicate the reason for seeking support and if you were happy with their service, treatment and/ or tests given? 

List any current health practitioners, and names of, that you are currently under the care of (GP, Chiropractor, Physiotherapist, Psychologist etc): 

Have you had any major dental work performed? If so, when?  

Did you have any complications at (your own) birth? 

Were you breastfed?

List any infections, allergies, intolerances, or other health issues as a child or teen:  

Please list any vaccinations you are aware you have been given. Did you react to any of them?  

Please list any family history conditions, medications or cause of death that you are aware of for siblings, parents and grandparents.

How would you describe your appetite? Do you experience any food cravings?  

Are you aware of any unhealthy eating habits? Eg. large quantities, eating quickly 

Do you use non-stick cookware? 

Do you store any food or drinks in plastic?

Do you use plastic wrap or alfoil regularly?

How often do you use a microwave to reheat food or drinks?

Are you vegetarian or vegan currently? If so, how long for?  

Have you been vegetarian or vegan in the past? If so, how long for? 

Do you consume seafood? If so, what type and how often? 

What other sources of protein do you consume on a weekly basis? (eg. eggs, poultry, red meat, nuts, seeds, legumes, protein powder) 

How many handfuls of vegetables (raw or cooked) would you consume over the day? 

What kinds of vegetables do you regularly consume? 

Do you consume any of these foods on a weekly basis?

Sauerkraut, home fermented yoghurt, home fermented kefir, home fermented kombucha, homecooked bone broth, homemade liver pate. Please list:

Do you consume alcohol? If yes, please describe your consumption across an average week 

Are there any other foods you avoid/ have eliminated from your diet? If so, please list them and the reasons for this diet change 

Please add any additional dietary info you wish to share: 

Please list details of any smoking or drug use: 

What does a typical brekkie, lunch , dinners snacks and drinks look like for you over the day?