artofhealing

naturopathic medicine

Adult Health Appraisal Questionnaire

Complete the following questionnaire.

Answer all relevant questions in as much detail as you can.

Todays Date: ____________________________________________________________________

Name: __________________________________________________________________________

Age: _______________________ DOB: _______________________Sex: ___________________

Address: ________________________________________________________________________

________________________________________________________________________________

Phone (home): __________________(work):____________________(mobile): ________________

Email: __________________________________________________________________________

Fax: ____________________________________________________________________________
Occupation: _____________________________________________________________________

Single/Partner/Married: ___________________________________________________________

Children: ________________________________________________________________________
Reason for naturopathic consultation:

List the symptoms or conditions you would like improved or treated in this consultation.

1. __________________________________________________________________________________

2. __________________________________________________________________________________

3. __________________________________________________________________________________

4. __________________________________________________________________________________

Current Medical History:

Have you been diagnosed with any of the following conditions?

[] diabetes [] epilepsy [] heart condition

[] cancer [] bleeding disorder [] thyroid condition
[] irritable bowel [] ulcerative colitis [] liver disease
[] asthma [] HIV/AIDS [] osteoporosis
[] rheumatoid arthritis [] kidney disease [] cardiovascular disease
Other: _________________________

Give details and symptoms of the above conditions. (When were you diagnosed, frequency, what
makes symptoms better or worse, treatments and were they successful?)
_____________________________________________________________________________________
_____________________________________________________________________________________

What medical tests or investigations have you had recently? (Include reason for test and results)
_____________________________________________________________________________________
_____________________________________________________________________________________

Do you have low iron levels? (When were you tested?)

_____________________________________________________________________________________

List any conventional medications that you are currently taking.

_____________________________________________________________________________________
_____________________________________________________________________________________

Are you allergic to anything? (eg. foods, medications, pollens, chemicals, moulds, animal hair)
_____________________________________________________________________________________
_____________________________________________________________________________________
List any vitamin or mineral supplements, herbs or homoeopathic remedies that you are currently taking.
(Include dosages)
_____________________________________________________________________________________
_____________________________________________________________________________________

Are you currently seeing any other health practitioners?

(eg. acupuncturist, osteopath, chiropractor, physiotherapist, counsellor)
_____________________________________________________________________________________
_____________________________________________________________________________________

General Health:

I feel that I have not felt well since. (eg. a particular event, illness, loss, trauma)
_____________________________________________________________________________________
_____________________________________________________________________________________

How many times a year do you get a cold or flu?

_____________________________________________________________________________________
_____________________________________________________________________________________

How often do you take antibiotics? (When was the last course taken?)
_____________________________________________________________________________________
_____________________________________________________________________________________

Do you suffer from any of the following?

[] twitching eye [] feeling faint [] dizziness

[] poor memory [] poor concentration [] tiredness and fatigue
[] poor wound healing
[] muscular cramps where? ___________________________________________________________
[] muscle weakness where? ___________________________________________________________

Do you suffer from? [] headaches or [] migraines

Describe symptoms of your headache or migraine. (eg. frequency, duration, time of day
what makes them better or worse foods/coffee/time day/stress, describe the pain and location)
_____________________________________________________________________________________
_____________________________________________________________________________________
Energy levels:

On a scale of 1 to 10 indicate where your energy levels are currently:

(Low) 12...3...4...5...6...7...8...9...10... (High)

Do you feel that you have an energy slump at a particular time of the day or night? (Around what time?)
_____________________________________________________________________________________
_____________________________________________________________________________________

Do you feel tired and lethargic after eating?

_____________________________________________________________________________________
_____________________________________________________________________________________

How do you feel first thing of a morning?

_____________________________________________________________________________________
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Sleep:

Do you feel that you are getting a good night sleep?

_____________________________________________________________________________________

How many hours sleep a night do you get on average?

_____________________________________________________________________________________

Do you have any problems getting to sleep?

(Explain eg. worrying about things, mind wont switch off, stress and anxiety)
_____________________________________________________________________________________

Do you have any problems staying asleep?

(Explain eg. need to go to the toilet, panic attack, baby wakes you)
_____________________________________________________________________________________

Do you wake at any particular time? (What time?)

_____________________________________________________________________________________

Do you suffer from sleep apnea?

_____________________________________________________________________________________
Do you snore?
_____________________________________________________________________________________

Do you get leg or feet cramps while you are sleeping?

_____________________________________________________________________________________

Diet Dairy:

Fill out the following diet diary in as much detail as possible.

(Include portions, beverages and roughly what time you eat each meal)

What do you eat and drink during a normal day?

Breakfast:
_____________________________________________________________________________________
_____________________________________________________________________________________

Mid-morning snacks:
_____________________________________________________________________________________
_____________________________________________________________________________________

Lunch:
_____________________________________________________________________________________
_____________________________________________________________________________________

Afternoon snack:
_____________________________________________________________________________________
_____________________________________________________________________________________

Dinner:
_____________________________________________________________________________________
_____________________________________________________________________________________

Dessert:
_____________________________________________________________________________________
_____________________________________________________________________________________

Before bed snack:

_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Dietary Information:

Are you a? [] vegetarian or [] vegan

Do you crave any foods in particular?

_____________________________________________________________________________________

List any other foods you eat regularly?

_____________________________________________________________________________________

How much water do you have daily?

_____________________________________________________________________________________

How many coffees do you have a day?

_____________________________________________________________________________________

How many teas do you have a day? (What type?)

_____________________________________________________________________________________

How many juices do you have a day?

(What type? eg. freshly squeezed, bottled, 100% juice, added sugar or fruit drink)
_____________________________________________________________________________________

How many soft drinks do you have a day? (What type?)

_____________________________________________________________________________________

Do you drink electrolyte sports drinks? (What type and how often?)
_____________________________________________________________________________________

How much alcohol do you have weekly? (What type?)

_____________________________________________________________________________________

Do you smoke cigarettes? (How many a day?)

_____________________________________________________________________________________

Do you take recreational drugs? (What type and how often?)

_____________________________________________________________________________________

Do you have problems eating any foods in particular?

_____________________________________________________________________________________

List any foods you dislike and wont eat?

_____________________________________________________________________________________
Do you have any of the following symptoms?

[] often thirsty [] dr y mouth

[] have trouble digesting fatty foods [] small appetite
[] large appetite [] always hungr y

How many pieces of fruit do you eat a day?

_____________________________________________________________________________________

Do you eat vegetables daily?

_____________________________________________________________________________________

Do you add salt to your food?

_____________________________________________________________________________________

Do you add sugar, artificial sweeteners or honey to meals or beverages? (What type and daily amount?)
_____________________________________________________________________________________

Are you sensitive to?

[] MSG [] sulphites (wine, dried fruits)

[] caffeine [] onion
[] garlic [] alcohol
[] sugar y foods [] spicy foods

Digestive Health:

Please indicate if you suffer from any of the following:

[] gluten intolerance (Coeliac) [] lactose intolerance

[] wheat intolerance [] milk protein allergy

Do you feel bloated after eating? (List foods)

_____________________________________________________________________________________

Do you get excessive flatulence after eating? (List foods)

_____________________________________________________________________________________

Do you burp often after eating? (List foods)

_____________________________________________________________________________________

Do you experience reflux, heartburn, or indigestion?

(Explain symptoms, what makes it worse eg. after a particular food)
_____________________________________________________________________________________
Do you experience abdominal pain or cramping?
(Explain eg. after a particular food, location of pain or cramping)
_____________________________________________________________________________________

Do you feel nauseous or vomit often? (What makes it worse or better?)

_____________________________________________________________________________________

How many times a day do you have a bowel movement?

_____________________________________________________________________________________

Do you suffer from constipation? (Explain eg. how often, after eating certain foods, when stressed)
_____________________________________________________________________________________

Do you have any pain or straining passing a stool?

_____________________________________________________________________________________

Do you suffer from diarrhoea? (Explain eg. how often, after eating certain foods, when stressed)
_____________________________________________________________________________________

Do you suffer from alternating constipation and diarrhoea? (Explain)

_____________________________________________________________________________________

Do you have haemorrhoids? (Explain eg. do they bleed, are they painful?)
_____________________________________________________________________________________

Describe your stool:

[] loose [] water y [] hard

[] undigested food particles [] contains mucus [] contains blood
[] floats [] sinks [] light clay colour
[] dark brown colour [] black coloured

Tongue diagnosis:

Look in the mirror at your tongue.

Do you have a white coating on your tongue?

(Is it thick or thin and what colour eg. white, cream, yellow, green, grey?)
_____________________________________________________________________________________

Do you have any cracks on your tongue? (Where?)

_____________________________________________________________________________________
Do you have an imprint of your teeth around the edge of your tongue?
_____________________________________________________________________________________

Is your tongue sore and red?

_____________________________________________________________________________________

Does your tongue tremble when you stick it out?

_____________________________________________________________________________________

Nail and Hair Health:

Do you have any white spots on your nails?

_____________________________________________________________________________________

Describe the health of your nails (eg. weak, split easily, soft, brittle, fungal infection)
_____________________________________________________________________________________

Do you have any problem with hair loss?

_____________________________________________________________________________________

Oral Health:

Do you suffer from any of the following?

[] cold sores [] ulcers [] dry lips

[] bleeding gums [] teeth problems [] gingivitis
[] bad breath [] cracked lips, corners [] cracked lips, centre
[] grind teeth [] loss of taste and smell Other: _________________

Give details and symptoms of the above conditions

(eg. frequency, what makes symptoms worse stress, when run down)
_____________________________________________________________________________________

Ear and Eye Health:

Do you suffer from any of the following?

[] recurrent ear infections [] tinnitus (ringing ears)

[] hearing problems [] perforated ear drum
Other: ___________________
Give details and symptoms of the above condition.
(eg. frequency, what makes symptoms worse stress)
_____________________________________________________________________________________

Do you suffer from any of the following?

[] short sightedness [] long sightedness

[] glaucoma [] cataracts
[] conjunctivitis [] styes
[] red eyes [] itchy eyes
[] dr y eyes [] water y eyes
[] yellow sclera [] dark circles around eyes
Other: ____________________

Nose and Respiratory:

Do you suffer from any of the following?

[] hay fever (allergic rhinitis) (seasonal or all year round?) ___________________________________

[] recurring tonsillitis [] asthma
[] sinusitis [] pneumonia
[] bronchitis [] wheezing
[] breathlessness on exertion [] frequent nose bleeds
[] nasal polyps Other: ____________________________________
_____________________

Give details and symptoms of the conditions above.

(eg. frequency, causative factors, what makes it worse pollens/a food/animal hair/time of year/stress)
_____________________________________________________________________________________

Do you currently have a respiratory infection? (Explain)

_____________________________________________________________________________________

Do you have any of the following symptoms?

[] congested, blocked nose [] runny nose, like a tap

[] nasal catarrh clear [] nasal catarrh yellow
[] nasal catarrh green [] nasal catarrh thick and ropy
[] nasal catarrh thin and watery [] nasal catarrh burns
[] sore throat [] swollen glands
[] red, swollen tonsils [] fever
[] aching muscles [] frequent sneezing
[] cough describe (eg. hard, dry, wet, ticklish) ___________________________
[] productive cough (cough up sputum)
[] unproductive cough (no sputum) Other:______________________
Cardiovascular Health:

Do you suffer from any of the following conditions?

[] High blood pressure (what was your last reading & when?) _______________________________
[] Low blood pressure (what was your last reading & when?) ________________________________
[] High cholesterol (what was your last reading & when?) ___________________________________
[] chest pain
[] heart palpitations
[] bruise easily
[] varicose veins
[] cold hands and feet
[] swollen feet or ankles
[] palpitations on exertion

What is your blood type?

_____________________________________________________________________________________

Are you generally a hot or cold person?

_____________________________________________________________________________________

Do you get fluid retention? (Where?)

_____________________________________________________________________________________

Do you sweat excessively? (Where?)

_____________________________________________________________________________________

Do you get night sweats?

_____________________________________________________________________________________

Urinary System Health:

Do you suffer from recurrent urinary tract infections?

(Explain eg. how often, symptoms, when was your last UTI, usual treatment?)
_____________________________________________________________________________________

Describe your urine:

[] clear colour [] dark yellow colour

[] offensive smell [] contains blood
Do you have any of the following symptoms?

[] urinar y incontinence [] frequent urination

[] pain urinating [] difficulty urinating
[] incomplete urination [] sudden urgency to urinate
[] urine leakage when cough

Describe the above symptoms.

_____________________________________________________________________________________

FEMALE Reproductive Health:

Do you take the contraceptive pill? (How long have you been on the pill and which one do you take?)
_____________________________________________________________________________________

Do you have vaginal thrush /candida? (How often do you get thrush? Describe symptoms.)
_____________________________________________________________________________________

Do you have any of the following symptoms?

[] vaginal discharge, cottage cheese like [] vaginal discharge, fishy odour

[] vaginal discharge, offensive after sex [] vaginal discharge, green
[] external genitalia, itchy [] external genitalia, burning and raw feeling
[] painful sex [] low libido

Do you suffer from any of the following conditions?

[] endometriosis [] fibroids [] poly cystic ovaries [] polyps [] breast lumps

Give details and symptoms of the condition above. (eg. when was it diagnosed, treatment)
_____________________________________________________________________________________

Do you have genital herpes? (How often do you get flare ups?)
_____________________________________________________________________________________

Do you have any other sexually transmitted diseases?

(List include symptoms and when did you contract STD)
_____________________________________________________________________________________
Preconception Care:

Are you planning on falling pregnant in the next 6 months?

_____________________________________________________________________________________

Have you been having difficulty falling pregnant? (How long have you been trying?)
_____________________________________________________________________________________

Would you like help with a preconception health plan?

_____________________________________________________________________________________

Pregnancy Health:

Are you pregnant at the moment? (How many weeks?)

_____________________________________________________________________________________

Is this your first pregnancy?

_____________________________________________________________________________________

Have you had any problems with past pregnancies?

(eg. miscarriage, gestational diabetes, ectopic pregnancy, pre-eclampsia)
_____________________________________________________________________________________

Have you had any spotting? (Explain)

_____________________________________________________________________________________

Do you have morning sickness? (What makes it better or worse?)

_____________________________________________________________________________________

Do you have any of the following pregnancy related conditions?

[] gestational diabetes [] pre-eclampsia / toxaemia

List any other symptoms associated with your pregnancy that you are concerned about?
_____________________________________________________________________________________

Postnatal Health:

Have you recently had a baby? (When?)

_____________________________________________________________________________________

Did you have a vaginal delivery or Caesarean?

_____________________________________________________________________________________
Were there any complications or trauma during the birth? (Explain)
_____________________________________________________________________________________

How has your recovery been after the birth?

_____________________________________________________________________________________

Are you currently breastfeeding, and if so have you had any difficulties? (Explain)
_____________________________________________________________________________________

Are you suffering from any of the following?

[] mastitis [] sore, cracked nipples

[] bleeding nipples [] breast abscess
[] low milk supply [] breast engorgement
[] nipple thrush [] blocked milk ducts
[] breast red and hot
[] pain when breastfeeding
Other: ______________________

Describe the symptoms above in detail.

_____________________________________________________________________________________

Menstrual cycle:

Do you have regular periods? __________________________________________________________

How many days is your menstrual cycle? __________________________________________________________

How many days do you bleed for? __________________________________________________________

Do you get mid cycle bleeding? __________________________________________________________

Do you have heavy or light periods? __________________________________________________________

Do you get any clotting? __________________________________________________________

Do you have any of the following menstrual problems?

[] absence of period [] irregular periods

[] painful periods [] ver y heavy periods

Give details of the above condition:

_____________________________________________________________________________________

Do you suffer from any of the following PMT symptoms?

[] sore breasts [] fluid retention

[] cramping [] irritability
[] mood swings [] depressed
[] cr y a lot [] sugar cravings
Other: _____________________

When do you get the above symptoms, before or during your period?
_____________________________________________________________________________________

Do you get period pain? (Before or during your period)

_____________________________________________________________________________________

What makes the pain better or worse?

(eg. pressure, hot water bottle, crunching over, stretching back, lying down, certain time day)
_____________________________________________________________________________________

When was your last pap smear and what was the result?
_____________________________________________________________________________________

Menopausal:

Are you?

[] pre-menopausal [] menopausal [] post-menopausal

When was your last period?

_____________________________________________________________________________________

Are you on HRT or considering going on HRT?

_____________________________________________________________________________________

Explain your menopausal symptoms (eg. hot flushes, vaginal dryness, depression, dry skin)?
(Include frequency, duration and how long have you had the symptoms, what makes symptoms
better or worse)

_____________________________________________________________________________________
Do you get any of the following symptoms associated with hot flushes?

[] flush comes from within out [] flush comes from the lower body to upper
[] sweating [] anxiety
[] redness [] shaking
[] night sweats Other: ______________________________

MALE Reproductive Health:

Do you have any problems with prostate health? (Explain) __________________________________

Do you have any difficulty sustaining an erection? _________________________________________

Do you suffer from premature ejaculation? ________________________________________________

Do you have a low sperm count or poor sperm morphology? _______________________________

Do you suffer from low libido? __________________________________________________________

Do you have genital herpes? (How often do you get flare ups?)
_____________________________________________________________________________________

Do you have any other sexually transmitted diseases?

(Describe symptoms and when you contracted STD?)
_____________________________________________________________________________________

Preconception Care:

Are you and your partner planning on falling pregnant in the next 6 months?
_____________________________________________________________________________________

Have you and your partner been having difficulty falling pregnant?
(How long have you been trying?)
_____________________________________________________________________________________

Would you like help with a preconception health plan?

_____________________________________________________________________________________
Skin Health:

Do you suffer from any of the following?

[] eczema [] psoriasis
[] tinea [] itchy scalp
[] warts [] skin cancer
[] dermatitis [] hives
[] dandruff [] itchy skin on body
[] yellow skin [] small bumps on back of arms
[] acne [] rash
[] white patches Other: ___________________________

Describe the symptoms above. (eg. what skin looks like, parts of body effected, how long you
have you had it for, what makes it better or worse heat/cold/creams/itching/rubbing/season).
_____________________________________________________________________________________

Is your skin dry or oily? ________________________________________________________________

Musculoskeletal Health:

Do you suffer from any of the following conditions?

[] arthritis [] rheumatoid arthritis

[] osteoarthritis [] gout

Describe symptoms of the condition above and when you were diagnosed?
(Include joints affected, treatments and were they successful, what makes symptoms better or worse?)
_____________________________________________________________________________________

Do you have any other musculoskeletal problems? (Explain)

_____________________________________________________________________________________

Exercise and Fitness:

How often do you exercise and what type of exercise do you do?
_____________________________________________________________________________________

Where do you rate your fitness?

(Not fit) 1...2..3..4..5..6..7..8...9..10..(Very fit)
If youre an athlete please include your training schedule, details about energy levels during and
after training, how well you recover and any other relevant information?
_____________________________________________________________________________________

Weight:

Are you happy with your weight? (Do you feel you need to lose or gain weight?)
_____________________________________________________________________________________

What is your weight and height?

_____________________________________________________________________________________

Do you have a history of dieting? (Explain)

_____________________________________________________________________________________

Have you ever suffered from an eating disorder? (Explain)

_____________________________________________________________________________________

For athletes, do you need to lose body fat or put on muscle mass?
_____________________________________________________________________________________

Emotional Health:

Would you say that you are a stressed, anxious person? (Explain what makes you feel this way)
_____________________________________________________________________________________

Have you ever had a panic attack? (Explain eg. when, how often, symptoms and possible cause)
_____________________________________________________________________________________

Indicate if you identify with any of the following emotions at the moment:

[] sadness [] guilt
[] jealousy [] joyless/lack of interest
[] thoughts of suicide [] worthless
[] cry a lot [] angry
[] lacking self confidence [] shyness
[] violent [] argumentative
[] perfectionist [] competitive
[] depressed [] outgoing
[] hyperactive [] like to spend a lot of time on my own
[] like company, need to be around people
Please explain how you are feeling emotionally at the moment?
_____________________________________________________________________________________

Explain if you suffer from any mental illness?

(eg. depression, bi polar, schizophrenia, obsessive compulsive disorder)
_____________________________________________________________________________________

Past Health History:

Have you suffered from any of the following childhood illnesses?

[] chicken pox [] scarlet fever

[] mumps [] measles
[] whooping cough [] glandular feve
[] rubella

As a child did you suffer from any recurring infections

(colds and flu, tonsillitis, ear infections, bronchitis)?
_____________________________________________________________________________________

Please list any other health events, including viruses, injuries, hospitalizations and operations in
the time line below:

0-5 years:
_____________________________________________________________________________________

5-10 years:
_____________________________________________________________________________________

10-20 years:
_____________________________________________________________________________________

20-30 years:
_____________________________________________________________________________________

30-40 years:
_____________________________________________________________________________________

40-50 years:
_____________________________________________________________________________________

50-60 years:
_____________________________________________________________________________________

60+ years:
_____________________________________________________________________________________
Family Health History:

List any known family diseases or illnesses such as diabetes, cancer, heart disease or mental illness
(depression, bi polar, schizophrenia)
_____________________________________________________________________________________

Additional Information:

Is there anything else you would like to mention that you think may be affecting your health?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 ONLINE NATUROPATHIC CONSULTATION
CONSENT FORM
Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopaths treat their patients
holistically, taking into consideration their physical, mental and emotional aspects. Natural medicines are generally
used in order to stimulate the bodys inherent healing capacity. A number of different approaches are used by natur-
opaths such as dietary changes, nutritional supplements, herbs, homoeopathic remedies and lifestyle changes.

Naturopathic medicines are generally considered safe and side effect free. Although rare, negative reactions to these
natural medicines can occur, such as an allergic reaction to a herb or an aggravation of pre-existing symptoms.

I understand that for a short period time I may experience worsening of symptoms or even new symptoms - this is called
a healing crisis. Although unlikely, this is generally considered a positive sign and shows the body is making positive
movement, and can signal the body is detoxifying.

Natural medicines should be used with caution when treating some conditions such as in pregnancy, diabetes, heart and
liver disease. It is very important therefore that you inform your naturopathic practitioner immediately of any disease
process that you are suffering from, or if you are pregnant, suspect you are pregnant or you are breastfeeding.

I understand that the interactions between herbs and prescribed drugs, are not yet well known, and that while unlikely
could have an adverse reaction or experience a reduction or increase in the effect of other medications. If you are
taking a prescribed medication and/or receiving other therapies please advise your doctor of what treatment and
supplements you may be receiving. Do not alter or cease medication without advising the prescribing practitioner. This
includes psychological and counseling therapies.

I realise that physical examination, which may or may not be a necessary or crucial element of your health assessment,
will not be possible during an online consultation.

I understand that a record will be kept of my personal health history. This record will be kept confidential and will not
be released to others unless so directed by myself or my representative or unless it is required by law. I understand that
the naturopath will answer any questions I have to the best of their ability. I understand that results are not guaranteed.
I do not expect the naturopath to be able to anticipate and explain all risks and complications. I will rely on them to
exercise judgment during the course of the procedure which they feel at the time is in my best interests, based upon the
facts then known.

[ ] I have fully read and understand the above information and with this knowledge, I
hereby consent to having an online naturopathic consultation with Lisa Guy.

Date: _________________________________

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