Pre-Consultation Questionnaire Pre-Consultation Questionnaire - Naturopathy If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Full Name * Address * Date of Birth * What is your occupation? * How did you hear about Dina? * What are your primary health concerns and what would you like to focus on in this appointment? * Past Medical History - Please list any major childhood accidents, surgeries or illnesses: Family History - Please list any major diseases that are present or have been present in your parents/grandparents/siblings (eg cancer, diabetes, heart disease): * What does your diet look like on an average day? Please list your breakfast, lunch, dinner, snacks and tea/coffee intake * What is your daily water intake? * How much alcohol do you drink per week? * Do you smoke? Or do recreational drugs? If so, how many and how often? * Please list any medications or supplements you are currently taking: * Do you have any allergies? If so, please give details: What do you do for exercise? Please give details: * Sleep - How many hours do you sleep per night? Do you have any issues sleeping? Do you wake up feeling refreshed on a morning? * How are your energy levels generally? Do you experience any slumps during the day, if so what time? * Gastrointestinal System (GIT) - Do you currently experience: Bad breathCold soresBleeding gumsNauseaVomitingDiarrhoeaConstipationBloatingA large amount of recent weight gain or lossBurpingFlatulenceReflux Bowel Movements - How often do you have a bowel movement? * Once a daySeveral times a dayOnce every 2-3 daysOnce a weekI take laxatives regularly to help me Bowels - Are your stools normally: (Not the nicest question to ask but it's important for your health) * YellowLight brownMedium brownDark brownGreenFloaters in the toilet bowlSinkers in the toilet bowlWell formedLoose/not well formedWith blood in them Respiratory System - Do you currently experience: HeadachesMigrainesDizzinessColds/Flu often throughout the yearSwollen glandsHayfeverSinus issuesNosebleedsCoughsShortness of breathAsthmaEar infections Urinary System - Do you currently experience: Extreme thirstPain on urinationNocturia (wake up repeatedly during the night to urinate)Bladder problemsCystitisUrinary Tract InfectionsThrush Reproductive System - Please give details of any issues you experience in this area: (For women, this could include irregular periods, menopause symptoms, PMS, irregular Pap Smears etc. For men, this could include infections, impotence or erectile concerns, hernias etc) Cardiovascular System - Do you currently experience: High or Low Blood PressureHeart problemsChest palpitationsCold hands and feetVaricose veins Musculoskeletal System - Do you currently experience: Muscle crampsMuscle spasmsBack painJoint painStiffnessParasthesia Do you suffer from any skin issues such as acne, eczema, dermatitis, psoriasis, warts etc? * Do you suffer from anxiety, depression, mood swings or panic attacks? * What are your health goals? *
