Client Form

Please fill in the form with your personal information and your consultation goals.

Client Information

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Country

Sex

Marital Status

Children

Children Age/s

Number of children and their age

Occupation

Height (cm)

Weight (kg)

Waist circumference (cm)

Refered by

Consent Form

Consent between the practitioner and client*

I understand the terms of engagement and agree that our professional relationship will be based on the information provided on this document

Agree

Consultation Form

Goals

Describe the two main goals for this consultation

Symptoms to address

Describe the two main symptoms that you would like to discuss and address during your consultation

Medical History

Provide a brief overview of your medical background, including history of childhood illnesses or relevant medical events, chronic conditions and past surgeries or hospitalizations

Medication/ Supplementation

List all medications you are currently taking, including prescriptions, over-the-counter medications and supplements (detailing brand name and dosage)

Family History

Indicate any significant medical conditions present in your family members (parents, grandparents and siblings)

Sleep Patterns

Indicate the average number of hours you typically sleep each night, as well as your usual bedtime and wake-up time

Exercise Routine

Describe your exercise habits, including the type of activities you engage in, how often you exercise and the duration of your workouts

Digestive function

Indicate the average number of bowel movements you have per day. If not daily, please specify how often

Allergies/ Intolerances

Specify any allergies or intolerances you have (including those related to food, the environment, medications, or any other substances)

Additional Information

Provide any additional information or details that you would like to share

Nutritional Form - 3 day diet diary

Breakfast

Share the time you typically eat breakfast and provide three breakfast options that you usually enjoy

Lunch

Share the time you typically eat lunch and provide three lunch options that you usually enjoy

Dinner

Share the time you typically eat dinner and provide three dinner options that you usually enjoy

Snacks

Share the time you typically eat snacks (morning/ afternoon/ night) and provide three snack options that you usually enjoy

Drinks

Share what and how much you typically drink throughout the day, including your daily water intake

* Consent between the practitioner and client

The naturopathic/ naturopathic nutrition practitioner

· Naturopathic/ Naturopathic nutritional advice will be tailored to support medically diagnosed conditions and/or health concerns agreed and identified by the two parties.

· Naturopathic/ Naturopathic nutritional practitioners are not permitted to diagnose or claim to treat medical conditions.

· Naturopathic/ Naturopathic nutritional therapy is not a substitute for professional medical advice and treatment.

The client

· You are responsible for contacting your GP or specialist about any health concerns you may have.

· Please advise your GP of the naturopathic nutrition protocol you will be following. Please also advise any other complementary medicine practitioners you are consulting.

· It is important that you tell your practitioner about any medical diagnosis you have received any prescription medication, herbal medicine or food supplements or over the counter medication you are taking as it may affect the naturopathic nutritional programme.

· If you are unclear about any part of your plan then you should contact your practitioner immediately for clarification.

· Your naturopathic programme and supplement plan will have a time frame and you should not continue with recommendations outside of this unless agreed by your naturopathic/ naturopathic nutritional practitioner. This is to avoid any adverse reactions.

· Please report any concerns about your programme to your naturopathic/ naturopathic nutritional practitioner for discussion at your next consultation.