GENERAL HEALTH NEW PATIENT INTAKE FORM – NATUROPATHY

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133 Catherine Street, Leichhardt NSW 2040
02 9555 8806

Confidentiality assured

General Health Questionnaire
Below are a series of health symptoms. Please check boxes with a tick for present symptoms. Please leave the box blank if you have never experienced this symptom.
Gastrointestinal Symptoms
Cardiovascular
Sleep
Respiratory
Immune/Lymphatic
Emotional
Endocrine
Urinary/renal
Female hormonal balance
Premenstrual symptoms
Skin
Sleep
Musculoskeletal
Male hormonal balance
Sexual Health
Medical History - self and family
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Three Day Diet Diary
This diet diary should be completed prior to your appointment with your naturopath and brought with you to your appointment. Please include as much details as possible eg. Type of bread used on sandwiches, whether food is packaged, takeaway or fresh, any dressings or oils used in cooking, any drinks etc....