Client Intake Form

Your Name (required)

First Name

Last Name

Email (required)

DOB (required)

Sex (required)

Phone number (required)

Address (required)

Emergency Contact (required)

Briefly describe your main health issues or concerns (required)

Do you have any existing medical conditions? (required)

Do you have any allergies or food intolerances (please specify) (required)

List all medications or natural remedies you are currently taking (incl. Panadol, oral contraceptive, etc.)

Pregnant (or chance of pregnancy)

Heart condition / High blood pressure

Medical devices / Implants / Joint replacement (required)

Liver or kidney disease (required)

Vegetarian / Vegan

Breastfeeding (required)

Diabetes (required)

Smoker/Vape

Message

Consent and Authorization (required)

I understand that the information provided on this form will be kept confidential and used for the purpose of my naturopathic care. I authorise the naturopath to provide me with health-related information and recommendations. I understand that whilst I am not obliged to provide any information, failure to provide full health details requested above or during consultations may compromise the quality of treatment provided. Parent/Guardian name if client under 18years of age.

Client Intake Form

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