No 1 Metabolic Balance practice in Australia 4 years running - 2020, 2021, 2022 and 2023

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Clinical Nutrition - Metabolic Balance - Naturopathy

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Health History

We are delighted to consult with you on your health needs!

In order to provide you with optimal health care we need for you to provide us with as much information in this form as possible.

Please complete the form with as much information as possible to assist PRIOR to our consultation.

YOUR OWN DETAILS:

Patiet ID

First Name

Last Name

Phone

LIFESTYLE:

Occupation

Actual Working Hours per week

List all medically diagnosed issues

List all Medications and Supplements in the last 2 years:

List all known family Medical Issues:

Check this if you smoke

Describe your level of activity/exercise:

How stressed are you?

Low

Medium

High

How much alcohol do you consume (on average)?

None - I don't drink

1-2 standard drinks per week

3-5 standard drinks per week

1-2 standard drinks per day

More than 2 standard drinks per day

Any information provided will be treated with complete confidentiality as per the Privacy Act 1988 (http://www.oaic.gov.au/privacy/privacy-act/the-privacy-act).

It may be necessary from time to time for my case to be discussed with other health professionals (e.g. medical specialists and/or complementary medical practitioners and provide my consent to part/all of my medical case notes to be released for these purposes only.

By ticking this box I am providing confirmation that I have read and accepted the above conditions.

Suite 6, 27 Cunningham Street, Newstead, QLD 4006

1300 03 03 25

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