New client health questionnaire

Your Details

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Emergency Contact Details

Medical Information

How can we help you?

Health Information

In a few words, please describe the state of your:

Sleep

Energy Levels

Stress

Mood/Mental Health

Weight

Food

Exercise

Smoking & Drugs

Female Clients Only

Current Conditions

Pathology

Please bring your most recent pathology result and any medical reports with you to your initial appointment.

Personal Health History

Family Health History

Please provide details for any significant health problems.

Mother

Father

Sibling(s)

Grandparents

Privacy Clearance and Legal Consent

I understand that Helen Ridge is a Naturopath and not a Medical Doctor. I give my permission for my health history and records to be kept on file for the purpose of Naturopathic treatment.

I understand that all information within my file will be kept confidential at all times. All information given within this questionnaire is a true and accurate representation of my health.
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LOCATION

We are situated in the beautiful Mt Maunganui, New Zealand.

Open Hours

Monday: 9am - 3pm
Wednesday: 9am - 3pm

LOCATION

We are situated in the beautiful Mt Maunganui, New Zealand.

Open Hours

Monday: 9am - 3pm
Wednesday: 9am - 3pm

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© Alive Natural Health 2018 | Website by: Solopreneur Support Services

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