New Client Intake Form
Please help me to provide you with the most appropriate treatment possible by taking the time to complete this information questionnaire carefully and completely. Any information you provide will be treated with complete confidentiality as per the Privacy Amendment (Private Sector) Act 2000.
Zest Infusion collects personal information in order to assist the provision of its services. Personal information will not be collected unless it is relevant for a purpose directly related to a function or activity of Zest Infusion.
Please be aware of our cancellation policy. We understand that life is unpredictable and you may not always be able to make your scheduled appointment. If you can’t make an appointment, please contact reception at least 24 hours prior to reschedule your appointment. Missed appointments and appointments cancelled without 24 hours notice will incur a fee of $80.00
Please bring with you copies of any recent blood test results to your appointment.
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Personal Information
- Surname *
- Given Names *
- Date of Birth *
DD slash MM slash YYYY
- Occupation *
- Country and city of birth *
- Referral *
- Email *
Issues and treatment:
- Have you seen a Natural Health Practitioner before? *
Yes
No
Type of Practitioner(s):
Reason:
Dates (the year):
What are your main health issues concerning you?
Treatment to date?
What major health issues have you had in the past?
Allergies
Intolerances
Hospitalisations
Current prescription medicines: Name of medicine Dosage per day Since when? Reason for taking ](javascript:void(0);) ](javascript:void(0);)
Current Supplements: Name of supplement and brand Dosage per day Since when? Reason for taking ](javascript:void(0);) ](javascript:void(0);)
Family History:
Alcoholism
Neurological conditions
Hypertension or other heart conditions
Osteoporosis
Allergies
Obesity
Infertility
Glaucoma
Dementia
Genetic disorder
Digestive problems
Stroke
Arthritis
Auto-Immune disorder
Asthma
Cancer
Mental Illness
Coeliac disease
Migraines
Diabetes
Thyroid conditions
Other
Other
Lifestyle check:
Cigarettes/day:
Coffee/day:
Alcohol/week:
Exercise/week:
Hobbies:
Sleep, hours per night:
Do you have any pets?
Review of systems:
Head:
Headaches:
Never
Rarely
Once every few weeks
Weekly
Daily
Migraines:
Never
Rarely
Once every few weeks
Weekly
Daily
Vertigo:
Never
Rarely
Once every few weeks
Weekly
Daily
Dizziness:
Never
Rarely
Once every few weeks
Weekly
Daily
Fainting:
Never
Rarely
Once every few weeks
Weekly
Daily
Eyes:
Allergies:
Never
Rarely
Once every few weeks
Weekly
Daily
Infections:
Never
Rarely
Once every few weeks
Weekly
Daily
Dryness:
Never
Rarely
Once every few weeks
Weekly
Daily
Vision disturbance:
Never
Rarely
Once every few weeks
Weekly
Daily
Ears:
Ear infections:
Never
Rarely
Once every few weeks
Weekly
Daily
Pain:
Never
Rarely
Once every few weeks
Weekly
Daily
Ringing:
Never
Rarely
Once every few weeks
Weekly
Daily
Eczema:
Never
Rarely
Once every few weeks
Weekly
Daily
Hearing difficulty:
Never
Rarely
Once every few weeks
Weekly
Daily
Nose:
Sinus congestion:
Never
Rarely
Once every few weeks
Weekly
Daily
Runny nose:
Never
Rarely
Once every few weeks
Weekly
Daily
Sneezing:
Never
Rarely
Once every few weeks
Weekly
Daily
Mouth/Throat:
Dryness:
Never
Rarely
Once every few weeks
Weekly
Daily
Strange tastes in mouth:
Never
Rarely
Once every few weeks
Weekly
Daily
Coating on tongue:
Never
Rarely
Once every few weeks
Weekly
Daily
Difficulty swallowing:
Never
Rarely
Once every few weeks
Weekly
Daily
Regular throat infections:
Never
Rarely
Once every few weeks
Weekly
Daily
Amalgam (mercury) fillings:
Yes
No
Dental problems:
Yes
No
Heart/Lungs:
Difficulty breathing:
Never
Rarely
Once every few weeks
Weekly
Daily
Palpitations (fast heartbeat):
Never
Rarely
Once every few weeks
Weekly
Daily
Pains in chest:
Never
Rarely
Once every few weeks
Weekly
Daily
Frequent chest infections:
Never
Rarely
Once every few weeks
Weekly
Daily
Digestive system:
Heartburn:
Never
Rarely
Once every few weeks
Weekly
Daily
Burping/belching:
Never
Rarely
Once every few weeks
Weekly
Daily
Regurgitation of food:
Never
Rarely
Once every few weeks
Weekly
Daily
Diarrhoea:
Never
Rarely
Once every few weeks
Weekly
Daily
Constipation:
Never
Rarely
Once every few weeks
Weekly
Daily
Abdominal pain:
Never
Rarely
Once every few weeks
Weekly
Daily
Nausea:
Never
Rarely
Once every few weeks
Weekly
Daily
Bloating:
Never
Rarely
Once every few weeks
Weekly
Daily
Flatulence/gas:
Never
Rarely
Once every few weeks
Weekly
Daily
Urine:
Frequent urinary infections:
Never
Rarely
Once every few weeks
Weekly
Daily
Genital itching or burning:
Never
Rarely
Once every few weeks
Weekly
Daily
Incontinence:
Never
Rarely
Once every few weeks
Weekly
Daily
Joints/Muscles:
Weakness:
Never
Rarely
Once every few weeks
Weekly
Daily
Pain:
Never
Rarely
Once every few weeks
Weekly
Daily
Cramps/spasms:
Never
Rarely
Once every few weeks
Weekly
Daily
Pins and needles:
Never
Rarely
Once every few weeks
Weekly
Daily
Numbness:
Never
Rarely
Once every few weeks
Weekly
Daily
Swelling:
Never
Rarely
Once every few weeks
Weekly
Daily
Loss of muscle tone:
Yes
No
Skin:
Discolouration:
Yes
No
Growths:
Yes
No
Dryness:
Yes
No
Easy perspiration:
Yes
No
Eczema/dermatitis:
Yes
No
Acne:
Yes
No
Hair loss:
Yes
No
Hives/allergic reactions:
Yes
No
Swollen or sore lymph glands:
Yes
No
Circulation:
Water retention:
Yes
No
Very cold hands and feet:
Yes
No
Varicose veins:
Yes
No
Discolouration of hands and feet:
Yes
No
Appetite/weight:
Easy weight gain:
Yes
No
Weight loss:
Never
Rarely
Once every few weeks
Weekly
Daily
Food cravings:
Never
Rarely
Once every few weeks
Weekly
Daily
Binge eating:
Never
Rarely
Once every few weeks
Weekly
Daily
Loss of appetite:
Never
Rarely
Once every few weeks
Weekly
Daily
Cognition:
Memory loss:
Never
Rarely
Once every few weeks
Weekly
Daily
Difficulty to focus/concentrate:
Never
Rarely
Once every few weeks
Weekly
Daily
Difficulty to make decisions:
Never
Rarely
Once every few weeks
Weekly
Daily
Low motivation:
Never
Rarely
Once every few weeks
Weekly
Daily
Learning difficulties:
Never
Rarely
Once every few weeks
Weekly
Daily
Emotional health/stress:
How regularly do you experience stress?
Never
Rarely
Once every few weeks
Weekly
Daily
Tendency to anxiety:
Never
Rarely
Once every few weeks
Weekly
Daily
Tendency to depression/low mood:
Never
Rarely
Once every few weeks
Weekly
Daily
Mood swings:
Never
Rarely
Once every few weeks
Weekly
Daily
Irritability:
Never
Rarely
Once every few weeks
Weekly
Daily
Gender *
Male
Female
For Females only:
History of fertility issues:
Yes
No
Irregular period:
Yes
No
Painful period:
Yes
No
Heavy period:
Yes
No
Pre-menstrual symptoms:
Yes
No
Low libido:
Yes
No
Menopausal symptoms:
Yes
No
Please tick the relevant box below if you have been diagnosed with any of the following conditions ...
Endometriosis
Polycystic ovarian disease
Fibroids
Unexplained infertility
Are you currently pregnant or breastfeeding:
Yes
No
Previous pregnancies:
Yes
No
Planning to have a baby in the next few months:
Yes
No
For Males only:
Low libido:
Yes
No
Low sperm count:
Yes
No
Dripping after urination:
Never
Rarely
Once every few weeks
Weekly
Daily
Weakened urine stream:
Never
Rarely
Once every few weeks
Weekly
Daily
History of fertility issues:
Yes
No
Diet overview
Please give an overview of your diet – give examples of what you will eat on a typical day:
Breakfast day 1
Breakfast day 2
Breakfast day 3
Midmorning snack day 1
Midmorning snack day 2
Midmorning snack day 3
Lunch day 1
Lunch day 2
Lunch day 3
Midafternoon snack day 1
Midafternoon snack day 2
Midafternoon snack day 3
Dinner day 1
Dinner day 2
Dinner day 3
Fluid intake:
Amount of water per day
Coffee:
Other:
Additional comments
I have read and answered all necessary questions