Client Registration - Naturopathic Medicine

Name *

First

Last

What is your # 1 Health Challenge? *

How much does this affect your life on a day to day basis? *

( Scale of 1-10, 1 being low, 10 being high)

Date of birth *

Gender *

Male
Female

Heirgh *

Weight *

Address

Phone number *

Email *

Profession *

Relationship status *

Single
Married/Partner
Divorced

Children? If any, how many and what age *

For female clients: Are you pregnant *

GP

How where you referred to me *

Have you seen before a Natural Medicine Practitioner? *

Yes
No

If yes please provide details of when and why *

What are the main reasons for coming to see me? *

When did you first became aware of your symptoms? *

What pharmaceutical medications are you taking? *

Name of medication I Reason for taking I Dosage & strengh

What supplements/herbs are you taking? *

Name of medication I Reason for taking I Dosage & strengh

Have you tried any other therapies for this condition? *

Do you have any known allergies? Please list. *

Food, environmental: gluten, eggs, dairy, nuts, selfish, mold, bee products

Do any of your other family members have similar health conditions? *

Details of any major ilnessess, surgeries, injuries, immunisations/vaccinations

Digestive health - upper *

Digestive health cont.

If you have anything else to add to this section please write them down here.

How many times per day do you have a bowel motion?

Do you have SIBO? Small Intestine Bacterial Overgrowth

Lower Gastrointestinal System *

Craving sweets in the afternoon? *

How would you rate your energy levels on a scale of 1-10 *

1= low, 10=high

Feeling low energy in the afternoon only? *

Please indicate the onset. E.g. around 2 pm or after lunch

How would you describe your appetite *

Which of the following do you consume?

How many times a week do you exercise and what do you do?

How many hours of work do you do per week?

How often do you get a cold/flu per year? *

Anything else you would like to add?

I have read and agreed to the T&C's as stated on the Kate Whyte's Natural Path website a.k.a. biomednz.com *

Yes