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)