Intake – Naturopathy Pg2

Intake Page 2

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    Step FIVE

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    Step SIX




    MEDICAL HEALTH

    Your MEDICAL Details

    Blood Group
    Blood Pressure


    FAMILY MEDICAL HISTORY

    Immediate Family Medical Condition(s)


    Paternal Family Medical Condition(s)


    Maternal Family Medical Condition(s)

    YOUR MEDICINES

    Orthodox / Pharmaceutical Medicines






    OTC Medicines




    Antibiotic Medicines

    Social Drugs






    Traditional / Herbal Medicines












    HEALTH SYSTEMS

    Please confirm your experience of each bodily system:
    Immune / Lymphatic System
    Respiratory System
    Skin, Hair and Nails
    Cancer
    Reproductive / Sexual Health
    Cardiovascular System
    Liver-Hepatic System
    Kidney (Renal) / Adrenal Systems

    Mouth and Throat Ophthalmic (Eyes) System Urinary System Nervous System
    Gastrointestinal System Digestive Symptoms Bowel- Stool Shape Stool Colour/Characteristics