New client health questionnairePlease enable JavaScript in your browser to complete this form.Your DetailsName *FirstLastAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDate of BirthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Skype NameOccupationEmergency Contact DetailsName *FirstLastContact PhoneRelationshipMedical InformationGP Name & PracticeGP PhoneHow did you hear about us?Who referred you?GPHealth ProfessionalFriend/ColleagueHow can we help you?What are the main health problems concerning you today?What are your top THREE health goals (in order of priority).On a scale of 1-10 (1 being poor, 10 being excellent), how would you rate your current health?Health InformationHeightWeightBlood GroupIn a few words, please describe the state of your:Gut HealthHormonal HealthLibidoImmune SystemAllergiesSleepSleep PatternsDeepRegularBrokenAverage hours a nightDo you wake up refreshed?YesNoOther comments/informationEnergy LevelsPlease rate your energy levelsVery LowLowMediumHighVery HighPlease provide detailsStressPlease rate your stress levelsMinimalAverageConsiderableUnbearablePlease provide detailsMood/Mental HealthDo you suffer fromDepressionAnxietyOther Mental Health ConditionPlease provide detailsWeightAre you happy with your current weight?YesNoMetabolism/WeightFoodPlease rate your appetitePoorAverageHeartyUncontrollableDo you experience any cravings?SugarSaltOtherPlease mention any food intolerances/sensitivitiesHow would you describe your usual diet?Are you open to making changes to your diet?YesNoWeekly consumption of caffeineWeekly consumption of alcoholExerciseCurrent fitness levelBelow averageAverageHighVery HighSmoking & DrugsAre you a smoker?YesNoDo you take recreational drugs?YesNoFemale Clients OnlyAre you:MenopausalPeri-menopausalDate of last periodIs your cycleRegularIrregularUsual cycle lengthUsual method of contraceptionOral contraceptive pillCondomsDiaphragmIUDOtherDo you have children?YesNoPlease give ages of your childrenAre you pregnant?YesNoIf yes - how many weeks pregnant are you?Are you breastfeeding?YesNoAre you planning a pregnancy in the next 18 months?YesNoCurrent ConditionsPlease tick if you suffer from:AllergiesAnaphylactic ReactionsAnxietyArthritisAsthmaAutoimmune ConditionBlood Clotting DisorderBowel ProblemsCancerChronic PainCirculation ProblemsDepressionDiabetesDigestive ProblemsEpilepsyFatigueFertility ProblemsGenetic DisorderHeadache/MigraineHeart ConditionHepatitis/Liver ConditionHigh/Low Blood PressureHIVHormonal ImbalanceKidney ConditionLowered ImmunityMenopauseMuscular PainNeurological ConditionOn Long Term MedicationPsychiatric DisorderRespiratory ConditionSkin ConditionSpinal/Joint ProblemsSports/Vehicle AccidentSurgery - Last 5 YearsThyroid ConditionUrinary Tract ProblemsWeight ProblemsPlease give any detailsPathologyHave you recently or in the past had abnormal pathology results? Please provide details.Personal Health HistoryPlease detail any past major illnesses, accidents, surgeriesFamily Health HistoryPlease provide details for any significant health problems.MotherAgeHealth problemsIf deceased, please detail causeAge at deathFatherAgeHealth problemsIf deceased, please detail causeAge at deathSibling(s)Age(s)Health problemsIf deceased, please detail causeAge at deathGrandparentsAge(s)Health problemsIf deceased, please detail causeAge(s) at deathPrivacy Clearance and Legal ConsentI 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.Digitally Signed:SignedFull Name: *Date:DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneSubmit Form
