Initial Health Questionnaire

Please answer each question in as much detail as possible.

Full Name

Date

Phone

D.O.B.

Occupation

Age

How did you hear about Suzie?

Address

Are you happy to receive updates and quarterly newsletters?

Do you have any children? (if so, please list their ages)

Please list any known allergies (food, medication, other) and any specific diets you are following (vegetarian, vegan, other)

Please outline 3 main health issues you wish to address during the course of your naturopathic treatment. Please include key symptoms you currently experience.

What do you believe the problem may be due to?

What kind of treatment(s) have you tried for the problem(s) listed above?

Has anything stopped you from achieving your health goals in the past? Examples may include not enough time, lack of support or not enough money. Do you think any of these may stop you from achieving your current health goals?

How would you like to feel?

How can Suzie best help you with your health?

How long do you think it will take, to achieve your health goals?

On a scale of 1-10, how committed are you to making changes to your diet and lifestyle? (10 being very committed)

Please list any medications, nutritional or herbal supplements you are currently taking (include dosage, brand & reason for taking):

How would you rate your energy levels?

How would you rate your daily stress levels on average?

What time do you wake up and go to bed?

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

Do you smoke? If so how much?

Do you drink alcohol? If so how much and how often do you drink?

Do you consume caffeine (coffee, energy drinks, black tea)? If so, how much?

How much water do you consume daily?

Physical Activity - type, duration and how often?

Please outline what you eat each day (including breakfast, lunch, dinner & snacks)

Privacy Clearance & Consent

I Agree

I understand that Suzie Weber is a Naturopath and not a medical doctor. I give permission for my health history to be kept on file for the purpose of naturopathic treatment; I understand that all information within my file will be kept confidential at all times. All information given within this questionnaire is to the best of my ability and is a true and accurate representation of my health.

CANCELLATION POLICY
This policy enables Suzie to better utilise available appointments for patients in need of health service. Please be courteous and notify myself by phone or email if you are unable to attend an appointment at least 24 hours prior to your scheduled appointment. Please note that if you miss an appointment or reschedule inside the 24 hours, 50% of the consultation fee will be charged.