Hannah Boyd Naturopath Personal Information PATIENT RECORD

Hannah Boyd
Adv.Dip.Nat, Adv.Dip.NM,
Adv.Dip.WHM, Adv.Dip.Hom
Naturopath
0402 191 049
[email protected]
www.new-leaf.com.au
PATIENT RECORD
Personal Information
Last Name
First Name
D.O.B
Age
Address
Phone
Sex
M/F/TG
Home
Work
Mobile
Email
Relationship
Occupation
Single
De facto
Doctor’s name
Married
Doctor’s phone
Doctor’s address
Health Fund Provider
Emergency Contact Details
Please list your health concerns in order of importanc
01
02
03
04
05
PTO
Referred by
Divorced/separated
page 2 of 3
PATIENT RECORD CONTINUED
Medical History
Height
Weight
Blood type
Weight 1 year ago
Please tick if you are currently experiencing or have ever experienced any of the following
Allergies / Hay fever
Chronic Fatigue Syndrome
Frequent diarrhea
Kidney disease
Anaemia
Chronic pain
Frequent urinary infections
Menstrual irregularities
Arthritis
Circulation problems
Glandular fever
Nausea
Asthma
Constipation
Gout
Osteoporosis
Bloating
Dental problems
Headaches or migraines
Prostate disease
Bruise easily
Depression
Heart problems
Psoriasis
Cancer
Dermatitis
Hepatitis
Recurrent infections
Candida
Diabetes
Herpes
Reflux or heartburn
Cardiovascular
disease
Dizziness or fainting
High Cholesterol
Sleeping difficulties
Eczema
HIV/AIDS
Thrush
Chest pain
Epilepsy
Hypertension
Thyroid disorder
Are you currently taking any prescription or pharmacy medicines?
yes
no
yes
no
yes
no
If yes, which ones
Are you currently taking any herbs or supplements?
If yes, which ones
Do you have any allergies, intolerances or sensitivities?
If yes, please summarise
Do you smoke?
yes
no
How many
per day?
Number of
years
Do you drink alcohol?
yes
no
Units/week
Type
FAMILY HISTORY
Please list any major illnesses that your close relatives may have experienced
PTO
page 3 of 3
PATIENT RECORD CONTINUED
General
Do you have any health
or lifestyle goals?
How would you rate your current state of health?
Excellent
Good
Fair
Poor
How do you rate your current energy levels?
Excellent
Good
Fair
Poor
3
5
How committed are you to improving your
health? (10 being very committed)
1
2
4
6
7
8
9
Are you willing to make changes to your diet?
Yes
No
Maybe
Are you willing to make lifestyle changes?
Yes
No
Maybe
How long do you feel it would take to achieve your health
and lifestyle goals?
Days
Weeks
Months
Years
What do you see as barriers
to your health goals?
Support
Resources
Commitment
Interest
Time
Money
10
I may contact you via email from time to time with newsletters, promotions and updates regarding our
practice. If you would not like to be added to my mailing list please tick the following box.
Agreement
I agree to provide medical information that is true and correct and will not withhold any information that could affect the outcome
of my consultation. I will inform the practitioner if any of the information I have given changes.
Signed
Date
The personal information collected on this form serves solely to help us understand your health and assist in case management.
The information will be kept in accordance with the Privacy Act 1988 as amended under the Privacy Amendment (Private Sector)
Act 2000 that protects all client information and binds us to confidentiality. We never disclose personal information of our clients
to third parties, unless the law requires us to or we have your verbal consent. All your information will be kept securely and you
have the right to access it at any time.
Parential Consent
(Parent or guardian to complete if the patient is under 18 years of age)
I _____________________________ of _____________________________________________________
consent to the specified complementary health care of _______________________________________ .
Signed:____________________________________________ Date: ________________________
(parent/guardian)
(address)
(client’s name)