New Patient Form

Your Contact Details

First name (required)

Last name (required)

Street address (required)

Suburb (required)

Postcode (required)

Your email (required)

Mobile number (required)

Home number

Date of birth (required)

Occupation

Emergency Contacts

Doctor's name

Doctor's contact details

Emergency next of kin

Emergency next of kin's contact details

Health Issues

Main issues (required)
Please outline the main health issues you'd like to focus on during the initial consultation.

Other issues
Please outline any other issues you'd like to address.

Allergies (required)
Please indicate if you have any allergies.

Major illnesses or surgeries (required)
Please indicate if you have had any major illnesses or surgeries.

Medications (required)
Please list any medications you take including when you take them and the dose.

Previous and Current Health Experiences

Please indicate if you have experienced or are currently experiencing any of the following health issues:

Heart and circulation
High blood pressureLow blood pressureHigh cholesterolHeart diseaseChest painBlood disordersVaricose veins

Mood
DepressionAnxietyTension / StressSleep disordersHeadaches / migrainesFatigueFibromyalgia

Respiratory
AsthmaHayfeverSinusitisOther breathing issues

Musculoskeletal
Spinal issuesMuscular painArthritisGoutOther bone disorders including osteoporosisNumbness or tinglingChronic pain

Digestion
Heartburn / RefluxConstipationDiarrheaDiabetesWeight gainWeight lossBloatingAbdominal pain

Skin and Hair
EczemaPsoriasisHair loss

Hormones
Prostate issuesThyroid dysfunctionBirth control / IUD / OCPHormonal imbalance

Family History

Please outline any health concerns that affect your parents, grandparents and siblings.

Social History

1. Do you have a partner?
YesNo
2. Are you a primary caregiver (parent or caring for someone)?
YesNo
3. Do you smoke cigarettes, vape or cannabis?
YesNo
4. Do you drink alcohol?
YesNo
5. How would you rate your diet?
012345678910

Additional information

Please upload any recent blood or imaging reports below:

Informed Consent

Please read and consent to the information below:
It is ethically required of Professional Health Practitioners to inform clients of the possible risks involved in naturopathic treatment, therefore only treatment methods deemed appropriate for the client will be used. Natural therapies are generally considered a safe treatment option for many health complaints, however, a naturopathic consultation should not be considered as a substitute for a medical examination or diagnosis. I acknowledge the risks associated with any naturopathic treatment and will inform my naturopath - Isabelle Taye - if there are any changes to my health which would affect my Treatment Plan.