Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 2PATIENT DETAILSTo gain the absolute best for your health from our comprehensive services, we ask that you fill in this form. Please take the time to answer all questions as honestly and accurately as possible. The more information you’re able to provide, the better we can tailor your treatment plan. All details will be held in the strictest confidence. Please bring this form completed with you to your first consultation. Thank you. Naturopathic consultations at Saltuary are generally broken down into the following: Initial consult: Seen as a ‘fact finding’ consult. We gather your information, history, perform relevant screenings and refer you to other practitioners if needed. Treatment is generally not given at this stage. Follow up consult: Generally held a week later to present you with our recommendations on how we plan to achieve your health goals. Treatment generally starts here. Further follow up consultations are generally held every couple of weeks after this, as and when needed.Name *FirstLastEmail *Date of BirthHEALTH SUMMARYHeightHow tall are you?WeightWe tailor our nutritional program to your body.Have you been to a naturopath / nutritionist / herbalist before?YesNoWhat is the main reason for your visit and what do you hope to gain from your consultation?If needed, how willing and able are you to make changes to your diet and lifestyle? Selected Value: 0zero for unwilling, 10 is extremely willingWhat barriers could prevent you from making these changes?Please note any objections to taking herbal medicine or supplements (eg: religious, cant swallow tablets, can’t stand the taste of herbal medicine, etc)ALLERGIESPlease share all your known allergies, including food, medications, herbs, or supplements.Please also indicate severity/anaphylaxis for any allergies.Medications and SupplementsPlease list any pharmaceutical medications you are takinginclude dosage, and why you are taking itPlease list all vitamins and supplements you are takinginclude dosage, and why you are taking itHave you had any blood tests or other types of investigations done in the last 12 months?YesNoIf yes, please list and bring these results with you to your initial consultation.Have you had any major surgeries?YesNoList your major surgeries and dateFAMILY MEDICAL HISTORYPlease list any major conditions / illnesses that the following people currently have or had. • Mother: • Father: • Paternal grandparents: • Maternal grandparents: • Siblings: • Children:Family Medical ConditionsPlease list who the person is in relation to you, the condition, and if they are still living.PATIENT MEDICAL HISTORYPlease mark (x) if you have any of the following chronic conditions:CancerHIV/AIDSTuberculosisDiabetesHeart diseaseHaemophiliaThyroid problemsEpilepsyOsteoporosisArthritis / RheumatismMetal pins / platesPacemakerLiver/Gall BladderPale / clay colored stoolsHistory of jaundiceHistory of Hepatitis A, B or CUnexplained itchingFatty foods cause indigestion and nauseaYellowish discoloration eyesImmune SystemColds / FlusCOVIDFrequent infectionsAllergies / hay feverThrushCold soresEar, Nose, and Throat (ENT)Sore throatTonsillitisEar infectionsSinusitisTinnitusAllergies / hay feverRespiratoryEmphysemaCoughPneumoniaDifficulty breathingAsthmaBronchitisWheezing / shortness of breathMusculoskeletalAches and painsJoint painJoint swellingMuscle cramps / twitchingHeadachesDisc herniation / protrusionsSciaticaCardiovascularHigh blood pressureLow blood pressureHigh cholesterolArrhythmiaStrokeDizzinessChest painBreathlessness on exertionLeg pain on exertionPalpitationsCold hands and feetEasy bruisingVaricose veinsNose bleedsUrinaryFrequent urinationDribbling urine after urinationStrong and sudden urge to urinateFrequent bladder infectionsBlood in urinePain or burning urinationGetting up at night to urinatePoor urine streamIncontinenceMucous in urineLower digestionIrritable bowel syndromeCrohn’s diseaseUlcerative colitisLower abdominal pain / crampingExcess gas or bloatingHemorrhoidsPolypsStools hard / dryStools loose / wateryStools floatStools sinkBlood / mucous in stoolsUndigested food in stoolsRegular laxative useUpper digestionHeartburn / acid refluxIndigestionBurpingStomach painSense of fullness after eatingNausea / vomitingDermatological / SkinAcneEczemaDermatitisPoor wound healingDry skinDandruffEmotional StateFeelings of anxietyFrequent sad thoughtsPanic attacksPessimistic / negative thoughtsFeelings of guiltDifficulty concentratingNervousnessChange in appetiteMetabolicSugar cravingsWeaknessFatigueDry skinBrittle hairWeight gainWeight lossSensitive to heatSensitive to coldIncreased thirstAnemiaChange in appetiteWomen's HealthPMS / PMTPainful periodsBreast tendernessBloatingFluid retentionIrregular cycles – long or shortOvarian cystsFibroidsEndometriosisAmenorrhoeaPCOSExcess facial hair / acneVaginal dischargeBlood clots in period.Heavy bleedingMenopausal problemsHysterectomyHot flushesHistory of miscarriageCurrently pregnantCurrently breastfeedingAbnormal pap smearThrush or vaginal itchingVaginal drynessCystitisHistory of STI’sLow libidoPregnant and/or breastfeedingMen's HealthProstate issuesLow libidoPain or swelling in groin/testesHistory of STI’sDifficulty sustaining an erectionDifficulty urinatingPoor beard or hair growthLifestyleDo you smoke?YesNoany substance – tobacco, cannabisHow often?Have you taken any other drugs (recreational or prescribed)YesNoWhat drug(s) and how often?Do you exercise?YesNoHow often?DietDescribe what you eat for a typical breakfast.Describe what you eat for a typical lunch.Describe what you eat for a typical dinner.Do you drink more than 1 unit of alcohol each day?YesNoHow many?How many of each do you drink per day?5 or more431-2NoneWater5 or moreWater 5 or more4Water 43Water 31-2Water 1-2NoneWater NoneCoffee or Tea – black5 or moreCoffee or Tea – black 5 or more4Coffee or Tea – black 43Coffee or Tea – black 31-2Coffee or Tea – black 1-2NoneCoffee or Tea – black NoneCoffee of Tea with Cream5 or moreCoffee of Tea with Cream 5 or more4Coffee of Tea with Cream 43Coffee of Tea with Cream 31-2Coffee of Tea with Cream 1-2NoneCoffee of Tea with Cream NoneFruit Juice5 or moreFruit Juice 5 or more4Fruit Juice 43Fruit Juice 31-2Fruit Juice 1-2NoneFruit Juice NoneSoft Drinks5 or moreSoft Drinks 5 or more4Soft Drinks 43Soft Drinks 31-2Soft Drinks 1-2NoneSoft Drinks NoneRate your daily energy level Selected Value: 01 = lethargic 10=full of vitality and energyRate your daily stress level Selected Value: 01= extremely stressed 10=peaceful blissHow is your sleep Selected Value: 0rate the frequency that you get at least 8 hour of sleep1= never 10-alwaysEMERGENCY CONTACT INFORMATIONEmergency Contact's Name *FirstLastRelation to Patient *Contact Number *Current Healthcare ProviderHealthcare Provider PhoneFile Upload Click or drag a file to this area to upload. Please upload any files relevant to your care you want us to review.Signature *Clear SignaturePlease sign. I agree that all of the information given in this form is true and correct. I shall advise of any health changes or new information as it comes. I make a commitment to my health and wellbeing today, and understand that the more open I can be with my practitioner, the more I shall get out of this.NextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit
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