HOME
ABOUT
NATUROPATHY
BOOK
BLOG
CONTACT
✕
NEW CLIENT INTAKE FORM
Step
1
of
12
- General
0%
Full name
First
Last
Date
MM slash DD slash YYYY
Age
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Email
Occupation
Emergency contact
Are you pregnant?
Number of Children and age
Height
Weight
Vitamins and supplements
Medications
Please list your current health concerns in order of importance
Are you diagnosed with any medical conditions?
Do you have any allergies or intolerances?
How did you hear about Sophie Jane?
If referred, please state by whom?
What would you like to get out of your visit at Sophie Jane?
Gastrointestinal
Indigestion
Yes
No
Excessive belching or burping
Yes
No
Bloating or fullness commencing during or shortly after a meal
Yes
No
Change in appetite
Yes
No
Reflux
Yes
No
Nausea
Yes
No
Vomiting
Yes
No
Constipation
Yes
No
Diarrhoea
Yes
No
Flatulence
Yes
No
Blood or mucous in stool
Yes
No
How often do you move your bowels?
Any recent overseas travel?
Any recent food poisoning or gastro?
Nervous system
Stressed
Yes
No
Anxious feelings
Yes
No
Depression
Yes
No
Overthinking
Yes
No
Mood changes
Yes
No
Headaches
Yes
No
Migraines
Yes
No
Changes in sleep pattern or quality
Yes
No
Anger
Yes
No
Immune system
Recurrent infections
Yes
No
Auto-immune disease
Yes
No
Cancer
Yes
No
Thrush
Yes
No
Cold Sores
Yes
No
Other
Ear, Nose, Throat and Respiratory
Sinus congestion
Yes
No
Sinus pain
Yes
No
Ringing in ears
Yes
No
Allergies/hay fever
Yes
No
Coughing
Yes
No
Wheezing
Yes
No
Asthma
Yes
No
Shortness of breath
Yes
No
Musculoskeletal
Joint pain
Yes
No
Muscular pain
Yes
No
Muscle cramping
Yes
No
Broken bones
Yes
No
Jaw clenching
Yes
No
Osteoarthritis
Yes
No
Rheumatoid arthritis
Yes
No
Endocrine system
Thyroid problems
Yes
No
Weight gain
Yes
No
Weight loss
Yes
No
Hot flushes
Yes
No
Excessive coldness
Yes
No
Hair loss
Yes
No
Sugar cravings
Yes
No
Skin
Acne
Yes
No
Eczema
Yes
No
Rash
Yes
No
Psoriasis
Yes
No
Slow wound healing
Yes
No
Easy bruising
Yes
No
General dryness
Yes
No
Genitourinary system
Painful urination
Yes
No
Increased frequency
Yes
No
Urinary Tract Infection
Yes
No
History of urinary tract infection
Yes
No
Blood in urine
Yes
No
Decreased urinary output
Yes
No
Kidney stones
Yes
No
Female reproductive system
Irregular cycles
Yes
No
PMS
Yes
No
Painful periods
Yes
No
Heavy periods
Yes
No
Breast tenderness
Yes
No
Pregnant
Yes
No
Peri-menopause
Yes
No
Menopausal
Yes
No
Sexually transmitted infection/disease
Yes
No
Male reproductive system
Erectile dysfunction
Yes
No
Low libido
Yes
No
Premature ejaculation
Yes
No
Sexually transmitted infection/disease
Yes
No
Prostate problems
Yes
No
Lifestyle
How would you rate your energy at the moment?
Please enter a number less than or equal to
10
.
How would you rate your happiness at the moment?
Please enter a number less than or equal to
10
.
How would you rate your sleep at the moment?
Please enter a number less than or equal to
10
.
How would you rate your stress at the moment?
Please enter a number less than or equal to
10
.
How often do you exercise?
Do you drink alcohol?
Yes
No
If yes, how many drinks per week?
Do you smoke cigarettes?
Yes
No
Do you take any recreational drugs?
Yes
No
Do you drink coffee or energy drinks?
Yes
No
Is there anything else you would like to add?
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
