MELANIE TURNER NATUROPATH
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Health Appraisal Form
Please fill out this form as best you can. When you are done, please click the submit button.
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Today's Date dd.mm.yyyy
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Name
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First
Last
Phone Number
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Email
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Date of birth
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Main Reasons For Consult
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Please tell me about the main reasons you would like to see a Naturopath.
Address
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Line 1
Line 2
City
State
Zip Code
Country
Occupation
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Please give details on the above condition/s
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When were you diagnosed? What have you tried? Anything that makes it better/worse? What are the main symptoms? Was there any illness or stressful event that brought it on?
Please list any medications you are taking
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Please write down any medications that you get from your doctor and any that you buy over the counter at the pharmacy. if none, please write "none".
Your Weight
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Your Height
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Have you ever been diagnosed with any of the following?
Choose Any
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Rheumatoid arthritis
Lupus
Hashimoto's
Grave's disease
Type 1 diabetes
Coeliac's
Crohn's Disease
Any other autoimmune disease
Comment
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Choose Any
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Type 2 diabetes
Pre-diabetes/insulin resistance
High blood pressure
High cholesterol
Sleep apnea
Fatty liver disease
Poly cystic ovarian syndrome
Cystic Acne
Endometriosis
Other menstrual distorder
Comment
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Choose Any
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Fertility issues
Erectile dysfunction
Any other illness
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Please list any family/genetic illnesses
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Please detail any tests or investigations that you have had recently
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Do you get any of the following
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Bloating
Reflux
Indigestion
Stomach cramps
Explosive bowel movements
Constipation
Diarrohea
Constipation and Diarrohea
How often do you get the above symptoms?
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How often do you open your bowels?
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Any other comment on your digestion
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Please pick the option that best describes you
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I am very happy and stress free
I have a lot of stuff going on, but I always push through and manage it
I am always worrying about everything
I have anxiety attacks for no apparent reason
I have no motivation and feel numb
I can't stop crying
Please go into more detail about the above symptoms
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If you experience any pain, please detail it here
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Please include how you rate the pain on a scale of 1-10 and how often it occurs. Please detail what the pain feels like for you.
Please add any other information that we haven't covered
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Male/Female/other
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Married/Single/Partner
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Children
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Please list any supplements that you take
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Including any vitamins, minerals or herbs that you are taking, including homeopathics, or superfood powders. If none, please write "none".
Choose Any
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Heart problems
Liver disease
Kidney disease
Blood borne virus
Asthma
Ecezema
Psoriasis
Osteoperosis
IBS
Irritable bowel
Gastrointestinal parasite (Blastocystis/Dientamoeba)
Autism Spectrum Disorder
Attention Deficit Disorder
Epilepsy
Depression
Anxiety
Cancer
Other mental illness
Comment
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When was the last time you saw your doctor and what did you see them for
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Are you pregnant/breastfeeding or trying to get pregnant?
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Please tell me about your menstrual cycle
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Length of cycle, heavy/light? If you aren't menstruating please explain why and detail how long it has been since your last bleed.
Please select the option that most describes you
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I sleep very well
I have trouble getting to sleep
I wake a lot during the night
I have trouble getting to sleep and wake during the night
Comments on sleep
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Reasons why you don't sleep well, or any other comment you'd like to make
Please rate your current energy levels out of 10
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with 1 being very low energy and 10 being the best you've ever felt.
Please list any allergies or food intolerances
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Do you experience any of the following?
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Head aches
Migraines
Vision problems
Dizziness
How often does this occur
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Any foods that you avoid? Please explain why
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What do you normally eat for breakfast
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What do you normally eat for lunch
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What do you normally eat for dinner
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List any snacks or cravings for certain foods.
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Please list any foods that you don't like and why
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How many coffees and tea per day?
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How much water do you drink per day
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How much alcohol do you drink per day/week/month?
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Submit
Home
Work With Me
Naturopathy
Naturopathic Testing
Naturopathic programs
Public Speaking and Workshops
Blog
About Me
Meet Melanie
Contact
Positive Feedback