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New Clients

WHAT TO EXPECT

Initial Consultations go for one hour. In this time a thorough case history is taken, this includes questioning around your past medical history, your diet, what your lifestyle is like, what has brought you in for your appointment and what you’d like to get out of your visits.

Your consultation will also include naturopathic diagnostic techniques such as examining your nails, skin, tongue and iris and some western medicine physical examinations.

This information is used to put together a complete picture of your current health state to create a treatment plan that suits your individual needs and meets your individual goals.

NEW CLIENT ONLINE FORM

Please complete the following form as thoroughly as possible prior to your visit. All information is confidential.

Full Name
Date of birth
Age
Address
Phone
Email
Occupation
Emergency Contact
Are you pregnant?
Number of Children
Height
Weight
What is your most important health concern?
Do you have any diagnosed medical conditions?
Known allergies or intolerances?
Suspected allergies or intolerances?
Current medications/supplements: (please list and include dosage and reason for taking)
Have you had any recent blood tests? (Please bring these along to your consultation)
What would you like to get out of your visit at Kismet Health?


Medical History

Please tick the corresponding box if you have had any concerns within the last year or of significance in the past.


Digestion/Gastrointestinal System

Change in appetite
YESNO
Reflux
YESNO
Bloating/fullness
YESNO
Discomfort/pain in abdominal region
YESNO
Nausea
YESNO
Vomiting
YESNO
Flatulence
YESNO
Constipation
YESNO
Diarrhoea
YESNO
Blood or mucous in stool
YESNO
How often do you move your bowels?
Any recent overseas travel?
Any recent food poisoning or gastro?

Nervous System

Anxiety
YESNO
Depression
YESNO
Mood changes
YESNO
Headaches
YESNO
Migraines
YESNO
Dizziness/light-headedness
YESNO
Numbness/tingling
YESNO
Seizures
YESNO
Loss of memory/concentration
YESNO
Change in vision
YESNO
Changes in sleep quality or pattern
YESNO

Ear, Nose, Throat and Respiratory

Ringing in the ears
YESNO
Seasonal allergies/hay fever
YESNO
Sinus pain/congestion
YESNO
Coughing/wheezing
YESNO
Shortness of breath
YESNO
Asthma
YESNO

Immune

Auto-immune disease
YESNO
Cancer
YESNO
Recurrent infections
YESNO
Thrush
YESNO
Bacterial Vaginosis
YESNO
Cold sores
YESNO

Skin

Acne
YESNO
Eczema
YESNO
Psoriasis
YESNO
Rash
YESNO
Excessive dryness
YESNO
Slow wound healing/ulcers
YESNO

Cardiovascular System

High blood pressure
YESNO
High cholesterol
YESNO
Heart disease
YESNO
Heart palpitations
YESNO
Cold hands/feet
YESNO

Musculoskeletal

Joint pain
YESNO
Muscle pain
YESNO
Muscle cramps
YESNO
Osteoarthritis
YESNO
Rheumatoid arthritis
YESNO
Broken bones
YESNO

Genitourinary System

History of urinary tract infections
YESNO
Painful urination
YESNO
Increased frequency
YESNO
Decreased output
YESNO
Blood in urine
YESNO
Kidney stones
YESNO

Endocrine System

Thyroid problems
YESNO
Sugar cravings
YESNO
Weight gain
YESNO
Weight loss
YESNO
Hot flushes
YESNO
Hair loss
YESNO

Female Reproductive System

Irregular cycles
YESNO
PMS
YESNO
Breast tenderness
YESNO
Painful or heavy periods
YESNO
Pregnant
YESNO
Menopause
YESNO
Female STDs
YESNO

Male Reproductive System

Erectile dysfunction
YESNO
Prostate problems
YESNO
Male STDs
YESNO


Children’s health

(please continue to next section if not applicable).

How was your child born (vaginally or C-section)?
Did your child have any complications during birth or pregnancy?
Was/is the child breastfed?
How long were they breastfed for?
When were solid foods introduced?
Has your child taken any antibiotics and how many?
Any behavioural changes or challenges?
Is your child progressing at school?
Has your child mentioned any bullying occurring at school?
Is your child a fussy eater?
Does your child have any sleeping difficulties?


Lifestyle

How would you rate your energy at the moment? (10= excellent 0=terrible)
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How would you rate your sleep at the moment? (10= excellent 0=terrible)
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How would you rate your stress at the moment? (10= excellent 0=terrible)
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When was your last course of antibiotics?
Do you do any of the following?
Drink alcoholSmoke cigarettes or marijuanaTake recreational drugsCoffee, tea, coke or energy drinksNone of the above


Family History

Has anyone in your family been diagnosed with a major illness? (E.g. Cancer, heart disease, diabetes, autoimmune disease, mood disorder, Alzheimer's disease, arthritis, high blood pressure, high cholesterol or other)
Are there any other health concerns or symptoms that you would like to mention?


Dietary analysis

Do you follow any specific diets?
Do you have any food allergies?
Do you often skip any meals?
If you skip meals, please state which ones
Do you crave any food?
Do you cook your food at home?
Who does most of the cooking?
Do you feel like you have enough cooking skills and knowledge?
How many takeaway meals do you have each week?

YesNo



24-hour food recall

(Please record what you have eaten for the past 24 hours, please provide as much details and be as honest as possible).

Breakfast:
Snack:
Lunch:
Snack:
Dinner:
Dessert:
Fluids:


Please be patient, this form may take a couple of minutes to submit.

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THE @KISMETHEALTH INSTAGRAM