Naturopathy Initial Form

About Your Session

Naturopathic Medicine is the treatment and prevention of disease by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity. A number of different approaches may be used throughout the course of treatment. Treatments include diet, lifestyle counseling, clinical nutrition (primarily via supplementation), botanical medicine, Homoeopathy, Bach flower remedies, Australian bush flower essences, and physical medicine.

Full name:

Why are you here today? Please list condition/s, and when you first noticed them?

Previous/current treatment for this condition:

Are you currently under the care of a physician or other health care professionals for this condition? (if yes, please give name and date of last visit)

What is your Blood Group:

Are you allergic to any of the following:
HerbsFoodsPollensVitaminsMedicinesOther (Please List)

If so, describe your reaction: (e.g: rash, itching, shortness of breath,etc)

Do you smoke? If Yes, how many?
YesNo

Do you drink alcohol? If Yes, how much?
YesNo

Family medical history if known (Please list condition and major illnesses):

List Medications or Nutritional Supplements/Vitamins you are taking:

Do you participate in regular physical activities? If Yes, what type, how often and how long for?
YesNo

Anything else we should know about?

Disclaimer
Even the gentlest therapies may cause complications in certain physiological conditions. This depends greatly on the individual and the extent of the illness. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease.
It is very important, therefore, that you inform your Naturopath immediately of any disease that you are suffering from as well as any medications (prescription or over-the-counter) that you are taking. If you are pregnant, suspect you are pregnant, or you are breast-feeding, advise your Naturopath immediately.

Statement of Acknowledgement
In order to clarify our position as health care practitioners, and our mutual responsibilities in your health care, we ask for your cooperation in signing this statement of acknowledgement.
1. That you understand that Naturopathic practitioners are not Medical Doctors; that we use non-invasive, natural methods of assessment and treatment of body dysfunctions.
2. That you understand that treatment and/or referral to other health practitioners is based upon the assessment of your health revealed through personal history, physical examination, laboratory testing and other appropriate methods of evaluation.
3. That you understand that the ultimate responsibility for your health care is your own, and that we are here to support you in this. We reserve the right to discontinue our services where it is apparent that your expectations and what we provide are not in agreement.
4. I understand that a record will be kept of health services provided to me. This record will be kept confidential and will not be released to others unless you give your consent or the law requires it.
5. I understand that my Naturopath will answer any questions to the best of her ability. I understand that results are not guaranteed. I do not expect my Naturopath to be able to anticipate all risks and complications, such as allergic reactions to supplements and herbs. I will rely on my Naturopath to exercise judgment during the course of the procedure, which they feel at that time is in my best interests based on the facts then known.

I understand this consent form is to cover the entire course of my treatments. I understand that I am free to withdraw my consent and to discontinue participation in these treatments at any time.

By typing my name below and clicking submit I agree that I have read and understood the above information.

Full name: