Health Questionnaire

MELANIE TURNER NATUROPATH

Home
Work With Me
Blog
About Me

Health Questionnaire

Health Appraisal Form

Please fill out this form as best you can. When you are done, please click the submit button.

* Indicates required field

Today's Date dd.mm.yyyy *

Name *

First

Last

Phone Number *

Email *

Date of birth *

Main Reasons For Consult *

Please tell me about the main reasons you would like to see a Naturopath.

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Please give details on the above condition/s *

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 *

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 *

Your Height *

Have you ever been diagnosed with any of the following?

Choose Any *

Rheumatoid arthritis Lupus Hashimoto's Grave's disease Type 1 diabetes Coeliac's Crohn's Disease Any other autoimmune disease

Comment *

Choose Any *

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 *

Choose Any *

Fertility issues Erectile dysfunction

Any other illness *

Please list any family/genetic illnesses *

Please detail any tests or investigations that you have had recently *

Do you get any of the following *

Bloating Reflux Indigestion Stomach cramps Explosive bowel movements Constipation Diarrohea Constipation and Diarrohea

How often do you get the above symptoms? *

How often do you open your bowels? *

Any other comment on your digestion *

Please pick the option that best describes you *

Please go into more detail about the above symptoms *

If you experience any pain, please detail it here *

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 *

Male/Female/other *

Married/Single/Partner *

Children *

Please list any supplements that you take *

Including any vitamins, minerals or herbs that you are taking, including homeopathics, or superfood powders. If none, please write "none".

Choose Any *

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 *

When was the last time you saw your doctor and what did you see them for *

Are you pregnant/breastfeeding or trying to get pregnant? *

Please tell me about your menstrual cycle *

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 *

Comments on sleep *

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 *

with 1 being very low energy and 10 being the best you've ever felt.

Please list any allergies or food intolerances *

Do you experience any of the following? *

Head aches Migraines Vision problems Dizziness

How often does this occur *

Any foods that you avoid? Please explain why *

What do you normally eat for breakfast *

What do you normally eat for lunch *

What do you normally eat for dinner *

List any snacks or cravings for certain foods. *

Please list any foods that you don't like and why *

How many coffees and tea per day? *

How much water do you drink per day *

How much alcohol do you drink per day/week/month? *

Submit

Powered by

Create your own unique website with customizable templates.

Home
Work With Me
Blog
About Me