Naturopathic consult form

Thank you for taking the time to complete this consult form prior to your consultation.

The information you provide will help me gain a first deeper understanding of your current health, lifestyle & wellbeing concerns, allowing us to then make the most of our time together to discuss further & put a plan in place!

Please answer as openly & honestly as you can, they'll be time to share further during our consult session too. There are no right or wrong answers, & all information shared is treated confidentially. I kindly ask that this form is completed at least 48 hours before your appointment where possible & submitted along with payment for our consult.

I look forward to supporting you on your wellness journey!

With love,

Sally

Natures Divine Wellness 🌿

Full name

Address

Phone

Birthday

Day

Month

Year

Occupation

Doctor registered with

Blood type if known

What would you most like to achieve from this consultation & health guidance ahead?

Please describe your main symptoms or concerns you're currently experiencing

Long answer

How is your energy currently?

How are your nails, skin & hair?

How are your teeth? Any fillings or root canals etc?

How is your sleep?

How is your digestion?

How are your bowels?

How is your menstrual health if applicable?

Do you have any children? Please list ages & how pregnany & birth generally was experienced

Please list any medication you are taking with dosages & how long these have been taken?

Please list any supplements you are taking with dosages & how long these have been taken?

Please describe a typical day's food intake?

& What fluids do you drink throughout the day?

Please tell me about any significant health history of yours since childhood?

& Were you vaccinated as a child?

Please tell me about any significant family health history of your siblings, parents, & grandparents? (if you know this)

Is there anything else you'd like me to know before our consultation?

Short answer

I understand that Naturopathic guidance complements but does not replace medical advice & treatment.

Date

Day

Month

Year

Naturopathic consult form

Ready to begin your healing journey?