New Client Questionnaire – Confidential

Home Resources New Client Questionnaire – Confidential

Before your first consultation please fill out this form.

Disclosure

Please note: This is not a medical practice. I acknowledge that Helen Ridge is a Naturopath and Nutritionist. All personal details will be kept confidential in accordance with Better Health Privacy Policy, unless legally required to disclose.

Personal Details

Title
 Miss Mrs Ms Mr

First Name (required)

Surname (required)

Email (required)

Date of Birth

Sex
 Male Female

Address

Telephone / Mobile

Health Fund

Referred by

Occupation

Other Health Practitioners

Marital Status
 Single Defacto Married Divorced Widow

Personal Health History

Past Accidents/Trauma

Surgery

Childhood & Other Illnesses

Allergies/Sensitivities (Food/Chemical/Grass/Animal/Dust/Mould) Other

Medication

Current Medication/Dose

Current supplements (Natural or Other)

Current Health Concern

Reason for consultation

How would you rate your overall health?
Rate out of ten

Diet

 Vegetarian Vegan High Protein Paleo Wheat free Yeast free Gluten Free Dairy free Red meat free

Takeaway:

Breakfast:

Morning Tea:

Lunch

Afternoon Tea:

Dinner:

Snacks:

Cravings:

Sweets/Chocolates:

Daily Water Intake:

 Tap Filtered Bottled

Herbal:

Soft Drinks:

Juices (Fresh/Bottled):

Alcohol (Beer/Wines/Spirits):

Lifestyle

Exercise/Sport:

Frequency:

Energy Level:
Rate out of ten:

Stress:

Relaxation/Creativity:

Sleep (Quality/No of Hrs):

Smoke
 Yes No

Recreational Drugs:

Socialising (Pubs/Restaurants/Café/Movies):

Any Self Development: