New patient intake form

Please note: Filling out this form does not book you in for a consultation – you will need to book an appointment via the bookings link

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General Information

Clear Health Solutions New Patient Intake Form

First Name

Last Name

Date of birth*

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Mobile Phone

Phone number (Home)

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Address*

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Emergency contact name

Emergency contact phone

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How did you hear about us?

Do you consent to receive the '5 steps to a healthier life' email series from James Marr Naturopathy?*

Yes

Current health concerns

Health concern 1

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Health concern 1 rating

Rate the degree of severity

Health concern 2

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Health concern 2 rating

Rate the degree of severity

Health concern 3

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Health concern 3 rating

Rate the degree of severity

Health concern 4

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Health concern 4 rating

Rate the degree of severity

Health concern 5

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Health concern 5 rating

Rate the degree of severity

Family health history

Check family members that have/had any of the following

	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	G.mother	G.father	G.mother	G.father
	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	G.mother	G.father	G.mother	G.father
Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune illness
Arthritis
Kidney disease
Thyroid problems
Seizures/epilepsy
Psychiatric disorders
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Irritable bowel syndrome
Dementia
Substance abuse
Genetic disorders

Medical historyIllnesses / conditions

Choose Yes for a condition you currently have, Past for a condition you've had in the past. Leave blank if not applicable.

Gastrointestinal

	Yes/Past
	Yes/Past
Irritable bowel syndrome
Reflux
Crohn's disease
Ulcerative colitis
Peptic ulcer disease
Coeliac disease
Gallstones

Respiratory

	Yes/Past
	Yes/Past
Bronchitis
Asthma
Emphysema
Pneumonia
Sinusitis
Sleep apnoea

Urinary / genital

	Yes/Past
	Yes/Past
Kidney stones
Gout
Interstitial cystitis
Frequent yeast infections
Frequent urinary tract infection
Sexual dysfunction
Sexually transmitted disease

Endocrine / metabolic

	Yes/Past
	Yes/Past
Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (high thyroid)
Infertility
Metabolic syndrome/Insulin resistance
Eating disorder
Hypoglycaemia

Inflammatory / immune

	Yes/Past
	Yes/Past
Rheumatoid arthritis
Chronic fatigue syndrome
Food allergies
Environmental allergies
Multiple chemical sensitivities
Autoimmune disease
Immune deficiency
Glandular fever
Hepatitis

Musculoskeletal

	Yes/Past
	Yes/Past
Fibromyalgia
Osteoarthritis
Chronic pain

Skin

	Yes/Past
	Yes/Past
Eczema
Psoriasis
Acne
Skin cancer

Cardiovascular

	Yes/Past
	Yes/Past
Angina
Heart attack
Heart failure
Hypertension (high blood pressure)
Stroke
High blood fats (cholesterol, triglycerides)
Rheumatic fever
Arrythmia
Murmur
Mitral valve prolapse

Neurologic / emotional

	Yes/Past
	Yes/Past
Epilepsy / seizures
ADD / ADHD
Headaches
Migraines
Depression
Anxiety
Autism
Multiple sclerosis
Parkinson's disease
Dementia

Cancer

	Yes/Past
	Yes/Past
Lung
Breast
Colon
Prostate
Skin
Other

If other, please specify

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Medical history cont...

Please enter date and comments of any procedures undertaken

Bone density scan

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CT scan

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Colonoscopy

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Cardiac stress test

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EKG

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MRI

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Upper endoscopy

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Upper GI series

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Chest X-ray

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Other X-rays

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Barium enema

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Other

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Please enter date and comments of any injuries present or past

Broken bone(s)

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Back injury

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Neck injury

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Head injury

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Other

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Please enter date and comments of any surgeries

Appendectomy

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Dental

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Gallbladder

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Hernia

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Tonsillectomy

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Joint replacement

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Heart surgery

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Other

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Please state date and reason for any hospitalisations

Hospitalisations

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Medications / supplements

Please state current medications (prescription and over the counter)

Medications

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Please state current nutritional / herbal supplements

Supplements

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Have medications / supplements ever caused any unusual side effects or problems?

Yes

If yes, describe

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Have you ever used any of these regularly or for a long time

NSAIDs, Aspirin

Panadol

Acid-blocking drugs (Zantac, Nexium etc)

Please state reason for antibiotic usage

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Have you ever taken any long-term antibiotics?

Yes

If yes, explain

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Naturopathic Medicine is the treatment and prevention of diseases by natural means. Naturopaths assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent capacity to heal. Your Naturopath will take a thorough case history, perform a pertinent physical exam and may suggest labwork or request copies of labwork previously completed by your family doctor or specialist. It is very important that you inform your Naturopath of any disease process that you are suffering from and any medications or over the counter drugs that you are taking. Please advise your Naturopath if you are nursing, are pregnant or become pregnant throughout the course of your treatment. As a patient you will receive information about your diagnosis and/ or treatment, alternative courses of action, costs, benefits, risks, side effects and in each case, the consequences of not having the diagnosis and/ or treatment acted upon. As with any form of medical intervention, there can be risks associated with treatment by naturopathic medicine. These include, but are not limited to: • Aggravation of pre-existing symptoms • Allergic reaction to supplements or herbs I understand that a record will be kept of the health services provided to me. The record will be kept confidential and will not be released to others unless so directed by myself or if the law requires it. If required, I understand that my Naturopath may discuss my case with other healthcare providers. I understand that results are not guaranteed. I do not expect my Naturopath to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to Naturopathic care I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent at any time.*

I have read the terms above and consent to treatment provided by Clear Health Solutions Pty Ltd:

Yes

Please type name*

Write here

	<5	>5
	<5	>5
Infancy / childhood
Teen
Adulthood

	<5	>5
	<5	>5
Infancy / childhood
Teen
Adulthood

New patient intake form

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General Information

Clear Health Solutions New Patient Intake Form

Current health concerns

Sleep

Nutrition

Dental history

Environmental / Detoxification history

Women's History

Men's history

Family health history

Medical historyIllnesses / conditions

Choose Yes for a condition you currently have, Past for a condition you've had in the past. Leave blank if not applicable.

Medical history cont...

Please enter date and comments of any procedures undertaken

Please enter date and comments of any injuries present or past

Please enter date and comments of any surgeries

Please state date and reason for any hospitalisations

Medications / supplements

Please state current medications (prescription and over the counter)

Please state current nutritional / herbal supplements

Symptom review

Please check if these symptoms occur presently or have occurred in the last 6 months. Leave blank if not applicable.

General

Head, Eyes, and Ears

Musculoskeletal

Mood / Nerves

Cardiovascular

Please check if these symptoms occur presently or have occurred in the last 6 months. Leave blank if not applicable.

Urinary

Digestion

Digestion cont...

Eating

Respiratory

Nails

Lymph nodes

Skin, dryness of

Skin problems

Skin problems cont...

Itching skin

Male reproductive

Please check if these symptoms occur presently or have occurred in the last 6 months. Leave blank if not applicable.

Female reproductive

Female reproductive cont...

Please sign

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