Patient Intake form - Britt Barkman Naturopath

Name

First

Last

Date of Birth

Age

Gender

F
M
More choices

Pronouns

A pronoun is a word that substitutes for a noun; in the case a word that substitutes for your name. Example: them, she, he.

Gender Assigned at Birth

F
M
Intersex
Decline to Answer

Knowing this is important because it relates to your physiological processes & allows me to treat you more appropriately.

Gender Identity

Trans F
Trans M
Gender Queer
Something Else
Decline to answer

Confirm Email

Would you like to receive newsletters & updates? You will always have the choice to unsubscribe.

Phone

Mobile

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Occupation

Health Fund

Emergency Contact

Name

First

Last

Phone

Parent or Guardian if under 18 yrs

Name

First

Last

Phone

Doctor's Details

Dr's name

Phone

Medical Specialists

Are you under the care of a medical specialist for any conditions?

List their names & contact details

Allied Health

Are you currently seeing any of the following?

Chiropractor
Kinesiologist
Physiotherapist
Personal Trainer
Feldenkrais Practitioner
Other

Chiropractor's name

Reason

Personal trainer's name

Reason

Kinesiologist's name

Reason

Feldenkrais practitioner's name

Reason

Physiotherapist's name

Reason

Other therapist's name & profession

Reason

Past Naturopathic Treatment

Have you ever visited a naturopath or herbalist before?

What sort of treatment did you have & for what reason?

What made you discontinue treatment?

Current Health

What is the reason for your visit?

Have you been diagnosed with an illness or condition?

Explain

Are you taking any medicines or supplements (include dosage & reason for taking)

Include those from the doctor, other practitioners, the health food store, the pharmacy or supermarket.
If you are not taking any, type 'none'

Do you have any allergies/life threatening conditions?

Explain

Test Results

It's incredibly helpful if you can supply copies of any testing you have had done. This includes testing from your doctor and any done by other practitioners you are seeing, or have seen recently.
If you can't supply these now, bring them to your consultation.

Upload copies of your latest blood tests, specialist or other results

Other

Weight

Height

Family History

Do you or anyone in your family experience any of the following?
Choose as many as needed.
M = maternal/mother's, P = paternal/father's

Allergies

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Asthma/ bronchitis

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Hayfever

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Skin Conditions

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Arthritis

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Heart Disease/ Stroke

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

High Blood Pressure

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Thyroid disorders

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Epilepsy

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Headaches/ migraines

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Obesity

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Diabetes

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Hepatitis

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Alcoholism or drug addiction

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Depression

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Anxiety

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Eating disorders

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Cancer

You
G/ma (M)
G/ma (P)
Mum
G/pa (M)
G/pa (P)
Dad

Other

Is this consultation for a child?

How was your child born?

Vaginaly
C-section

List any complications that may have occured during your child's birth

List any vaccinations your child has had.

When were they given? Did they have any bad reactions?

Was/ is your child breastfed?

For how long?

Why was this?

When was solid food introduced?

Is your child experiencing any of the following?

Behavioural issues
Bullying
Poor sleep
Fussy eating
Learning difficulties
Other

Choose as many as necessary

Please give more detail

Lifestyle

How would you rate your energy levels? (10 highest - 1 lowest)

How stressed do you feel? (10 extremely - 0 little)

How well do you sleep? (10 very well - 0 poorly)

Do you smoke?

Have you smoked in the past?

How many per day or week, or socially?

Do you drink?

How often?

Occasionally
Every weekend
3-4 times a week
Every day

How how many drinks per day?

When was your last course of antibiotics?

For what reason?

Have you ever worked with or been exposed to any sort of chemicals?

What were they?

Have you travelled overseas recently?

Where did you go?

Diet

Are you following a specific diet?

What is it?

For what reason?

Are there any foods that make you feel unwell?

What are they?

Do you crave any particular foods?

What are they?

Do you skip meals regularly?

Which ones?

Breakfast
Lunch
Dinner

Why?

Digestive System

Have you ever experienced any of the following?

Changes in appetite
Reflux
Bloating/ fullness
Discomfort in the lower abdomin
Migraines
Nausea
Vomiting
Flatulence
Constipation
Diarrhoea
Blood or mucous in the stool
Recent food poisoning or gastro

How many bowel motions do you have a day?

Nervous System

Have you ever experienced any of the following?

Anxiety
Depression
Mood changes
Headaches
Migraines
Dizzyness/ feeling light headed
numbness/ tingling
Seizures
Loss of memory
Poor concentration
Change of vision
Changes in sleep quality or pattern

How many hours do you sleep?

What time do you wake & go to bed?

Respiratory System

Have you ever experienced any of the following?

Ringing in the ears
Post nasal drip
Morning cough
Wheezing
Asthma

Immune System

Have you ever experienced any of the following?

Frequent colds & flu
Coldsores
Recurrent infections

Details/ Other

Have you ever had cancer?

Give details

Skin

Have you ever experienced any of the following?

Eczema or dermatitis
Psoriasis
Dry skin
Rashes
Slow wound healing

Details/ Other

Cardiovascular System

Have you ever experienced any of the following?

High blood pressure
Low blood pressure
Heart disease
High cholesterol
Heart Palpitations
Cold hands and feet

Details/ Other

Musculoskeletal System

Have you ever experienced any of the following?

Joint pain
Muscle pain
Muscle cramps
Osteoarthritis
Rheumatoid arthritis
Broken bones

Details/ Other

Genitourinary System

Have you ever experienced any of the following?

Urinary tract infections
Painful urination
Increased frequency
Getting up multiple times during the night to urinate
Decreased output
Blood in urine
Kidney stones

Details/ Other

Endocrine System

Have you ever experienced any of the following?

Hypothyroidism
Hyperthyroidism
Sugar cravings
Weight gain
Weight loss
Hotflushes
Hair loss

Details/ Other

Reproductive System

Have you ever experienced any of the following?

Irregular periods
PMT
Breast tenderness
Painful periods
Heavy periods
STDs
Fibroids
Fibrous/Lumpy breasts

Are you pregnant?

How far along?

How many children do you have?

Have you ever had a miscarriage?

Details/ Other

Have you ever experienced any of the following?

Erectile dysfunction
Prostate problems
STDs
Difficulty urinating

Details/ Other

Questions

Please ask any questions here

Terms and Conditions

Patient Agreement *

I have read and agree to the patient agreement.

The information I have given is to the best of my knowledge accurate and I will provide any additional information that may come to my attention.

I understand that I am responsible for informing the practitioner of any medications I am currently taking, and that any changes or additions must be reported as they occur.

I am aware that any information I provide is private and confidential and will not be passed on to any third parties without my permission.

I understand that this is not a medical practice and Britt Barkman is not a medical practitioner.

Website Terms and Conditions *

I have read and agree to the terms and conditions of this website.

Date *

Congratulations, you're done. Please be patient while submitting your information. It could take a while!

Emergency Contact

Parent or Guardian if under 18 yrs

Doctor's Details

Medical Specialists

Allied Health

Past Naturopathic Treatment

Current Health

Test Results

Other

Family History

Lifestyle

Diet

Digestive System

Nervous System

Respiratory System

Immune System

Skin

Cardiovascular System

Musculoskeletal System

Genitourinary System

Endocrine System

Reproductive System

Questions

Terms and Conditions

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