Health Questionnaire

Please enable JavaScript in your browser to complete this form.
Step 1 of 2

PATIENT DETAILS

To 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

HEALTH SUMMARY

How tall are you?
We tailor our nutritional program to your body.
Selected Value: 0
zero for unwilling, 10 is extremely willing

ALLERGIES

Please also indicate severity/anaphylaxis for any allergies.

Medications and Supplements

include dosage, and why you are taking it
include dosage, and why you are taking it
If yes, please list and bring these results with you to your initial consultation.

FAMILY MEDICAL HISTORY

Please list any major conditions / illnesses that the following people currently have or had. • Mother: • Father: • Paternal grandparents: • Maternal grandparents: • Siblings: • Children:
Please list who the person is in relation to you, the condition, and if they are still living.

PATIENT MEDICAL HISTORY

Please mark (x) if you have any of the following chronic conditions:
Liver/Gall Bladder
Immune System
Ear, Nose, and Throat (ENT)
Respiratory
Musculoskeletal
Cardiovascular
Urinary
Lower digestion
Upper digestion
Dermatological / Skin
Emotional State
Metabolic
Women's Health
Men's Health

Lifestyle

any substance – tobacco, cannabis

Diet

How many of each do you drink per day?
5 or more431-2None
Water
5 or more
4
3
1-2
None
Coffee or Tea – black
5 or more
4
3
1-2
None
Coffee of Tea with Cream
5 or more
4
3
1-2
None
Fruit Juice
5 or more
4
3
1-2
None
Soft Drinks
5 or more
4
3
1-2
None
Selected Value: 0
1 = lethargic 10=full of vitality and energy
Selected Value: 0
1= extremely stressed 10=peaceful bliss
Selected Value: 0
rate the frequency that you get at least 8 hour of sleep1= never 10-always

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name
Click or drag a file to this area to upload.
Please upload any files relevant to your care you want us to review.
Please 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.
en_USEnglish