Patient Intake Form First Name(s)Last NameDate of Birth DD slash MM slash YYYY AddressHome PhoneCell phoneCityPostcodeEmail OccupationDoctors ClinicWhere did you hear about us?Blood GroupUsual Blood PressureEnergy LevelPlease rate the following on a scale of 1 (low) to 10 (High)10 Extremely High9 Very High8 Very High7 High6 Above Average5 Medium4 Below Average3 Low2 Very Low1 Blissfully LowStress LevelPlease rate the following on a scale of 1 (low) to 10 (High)10 Extremely High9 Very High8 Very High7 High6 Above Average5 Medium4 Below Average3 Low2 Very Low1 Blissfully LowHappinessPlease rate the following on a scale of 1 (low) to 10 (High)10 Extremely High9 Very High8 Very High7 High6 Above Average5 Medium4 Below Average3 Low2 Very Low1 Blissfully LowPlease describe the MAIN HEALTH CONCERN or symptoms that you are seeking help withPlease describe your MAIN HEALTH GOALS for the next 12 monthsAnd your MAIN HEALTH GOALS FOR LIFEPlease describe any important secondary symptoms or health concerns that you have (if any)What is your usual breakfast?What is your usual lunch?What is your usual dinner?What usual snacks do you have between meals? (if any)How many glasses of water do you drink every day?What other liquids do you have daily? (Other than water)Use the Plus+ symbol on the right to add more drinksDrinkCups per day DENTAL – Any ROOT CANALS?Please select oneNoYesHow many MERCURY FILLINGS?SYMPTOMS CHECKLISTTo enable us to gain a complete view of your health, please tick if you have any of the following:GENERAL Headaches/Migraines Fever/Chills Fainting Dizziness Loss of Sleep Nervousness Weight Gain/Loss Numbness/Pain in Arms/Legs Neuralgia Change in Thirst EAR, NOSE, THROAT Failing vision/Squint Deafness Earache/Ear Noises Ear Discharges Nose Bleeds Nasal Obstruction Sore throat/hoarseness Asthma Gum Trouble Enlarged Thyroid Tonsillitis’s Sinus Infection Enlarged Glands SKIN Skin Eruptions Itching Bruise Easily Dryness Boils/Acne Varicose Veins Sensitive Skin Shingles RESPIRATORY Chronic Cough Dry chesty Cough Productive Cough Spitting up Phlegm Spitting up Bood Chest Pain CARDIOVASCULAR Irregular Heart Beat Blood Pressure High/Low Pain Over Heart Previous Heart Attacks Hardening of Arteries Swelling of Ankles Poor Circulation Paralytic Stroke Blood Clots GENITOURINARY Frequent Urination Painful Urination Urine Discolouration Kidney Infection or Stones Inability to Control Urine Prostate Concerns Urine Slow to Start Urinary track infection/s GASTROINTESTINAL Poor Appetite Excessive Hunger Indigestion Belching/Flatulence Nausea/Vomiting Heartburn Pain Over Stomach Abdomen Distended Constipation Diarrhoea Haemorrhoids Intestinal Worms Liver Trouble Gall Bladder Trouble Jaundice WOMEN ONLY Painful Nenstruation Excessive Flow Hot Flushes Cramps or Backache Previous Miscarriage Vaginal Discharge Congested Breast Lumps in Breast Menopausal Problems PMS DIAGNOSED DISEASES- if you have ever been diagnosed with any of the following diseases, please tick Appendicitis Pneumonia Rheumatic Fever Pleurisy Tuberculosis Alcoholism Arthritis Venereal Disease Epilepsy Mental Disorder Gastric Ulcers Anemia Hepatitis Herpes Diabetes Aids Thyroid Cancer Heart Disease Glandular Fever Thrush Cystitis Meningitis Malaria Depression Irritable Bowel Any other diagnosed disease?Any Major Surgery?Any broken bones ?MEDICAL TESTSPlease gives results of any investigations, X-rays, mammograms, test in last 5 yearsPRESCRIPTON DRUGSHave you used any of the following? Please indicate frequency and duration Antibiotics Steroids Contraceptive Pills Sleeping Pills Antidepressants Other Name of, frequency & duration of AntibioticsName of, frequency & duration of SteroidsName of, frequency & duration of Contraceptive pillsName of, frequency & duration of Sleeping pillsName of, frequency & duration of AntidepressantsList the name, frequency and duration of any other prescription drugsALLERGIES AND SENSTIVITIESDescribe any allergies or food reactions that you experienceFAMILY HISTORYPlease note major diseases or causes of death for parents, grandparents or siblingsLIFESTYLE AND HABITSWhat exercise do you do and frequency?What alcohol do you drink and how often?Do you smoke? If so how much / since when?Do you use any recreational drugs? If so how often?Hours of Sleep per Night?Frequency of Bowel Motions?per dayAre you either Vegetarian Vegan What proportion of your diet is uncooked/unprocessed?Do you have any food cravings?SUPPLEMENTS AND HERBSPlease list any food supplements or herbs that you take regularlyOTHER INFORMATIONPlease write candidly about anything you feel may be relevant that may not have been covered in the questions above: eg trauma, life situation, your aspirations, understandings about your health concerns.TERMS OF CONSULTATION – IMPORTANTAll information provided by New Zealand Herbals is for educational purposes only and is not intended as a substitute for professional medical advice, diagnosis or treatment. I accept responsibility for contacting my GP or specialist about any Health Concerns I may have. I will advise my GP or specialist about any treatment protocol I am following.Name of Client*Acceptance of Terms of Consultation stated above* I ACCEPT
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