Initial Consultation Health Details · DATE: NAME: DOB: ALLERGIES: Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counselling

DATE: NAME: DOB: ALLERGIES:

Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counseling | Herbal Medicine

Mobile: 0431 221 253 | [email protected] | Fax: 02 6678 0424

Initial Consultation Health Details PATIENT DETAILS

DATE OF FIRST VISIT SURNAME FIRST NAME

DOB SEX CURRENT AGE WEIGHT HEIGHT

REFERRED BY PRIVATE HEALTH INSURANCE PROVIDER

ADDRESS

PHONE (H) PHONE (M) EMAIL

OCCUPATION PREVIOUS OCCUPATION

MARITAL STATUS CHILDREN: YES/NO (IF YES, LIST AGES)

LIST YOUR HEALTH PROFESSIONALS INCLUDING YOUR DOCTOR

NAME PHONE

PROFESSION

NAME PHONE

PROFESSION




NAME PHONE

PROFESSION

NAME PHONE

PROFESSION

NAME PHONE

PROFESSION

NAME PHONE

PROFESSION



Mobile: 0431 221 253 | [email protected]| Fax: 02 6678 0424

HEALTH DETAILS

PRESENTING COMPLAINT/SYMPTOMS (describe in detail – onset, duration, frequency, triggering factors)

PAST ILLNESSES OR MEDICAL CONDITIONS

ALLERGIES OR INTOLERANCES




TIMELINE

Please give a brief description of the history of your health including any diagnosis, conditions, injuries, operations, major events or traumas starting from most current going back to childhood:

AGE HEALTH ISSUE/LIFE EVENT


Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counselling | Herbal Medicine

Mobile: 0431 221 253 | [email protected] Fax: 02 6678 0424

FAMILY HEALTH HISTORY

Please list all physical and mental health conditions for your primary family members:

PATERNAL MATERNAL

FATHER MOTHER

GRANDFATHER GRANDFATHER

GRANDMOTHER GRANDMOTHER

SIBLINGS (LIST BIRTH ORDER OF PATIENT)

UNCLES, AUNTS, COUSINS UNCLES, AUNTS, COUSINS




PHARMACEUTICAL MEDICATIONS

PRESENT PAST

COMPLEMENTARY AND ALTERNATIVE MEDICATIONS

PRESENT PAST

LIFESTYLE

OCCUPATIONAL HAZARDS

RECENT CHANGES (SHIFTS, JOBS, RELATIONSHIPS, RENOVATIONS, TRAUMA, ETC.)




LIFESTYLE

EXERCISE OR HOBBIES

ALCOHOL, SMOKING OR RECREATIONAL DRUGS

SUPPORTIVE RELATIONSHIPS

BELIEFS, PHILOSOPHY OR RELIGION

RATE STRESS LEVEL (0-10), LIST KNOWN CAUSE




PATIENT’S USUAL DAILY DIET

MEAL TIME FOOD AND FLUID CONSUMED (include amounts with clear descriptions)

Rising

Breakfast

Morning tea

Lunch

Afternoon tea

Evening meal

Supper

Other

OTHER DIET FACTORS

WATER CAFFEINE

ALCOHOL RECENT CHANGE IN FOOD HABITS

CRAVINGS DISLIKES

DIET QUALITY AND COOKING METHODS (e.g. BBQ, fried, steamed, use of fresh/processed foods, variety, nutritional philosophy)




DIET SURVEY

Please check the most commonly eaten foods and list how many serves:

FRESH PRODUCE SERVES/DAY

☐ Spinach

☐ Kale

☐ Asian greens

☐ Collard greens

☐ Peas

☐ Beans

☐ Asparagus

☐ Cabbage

☐ Broccoli

☐ Cauliflower

☐ Seaweeds, etc.

☐ Other – please specify type

SALAD SERVES/DAY

☐ Lettuce

☐ Rocket

☐ Watercress

☐ Sprouts

☐ Tomato

☐ Cucumber

☐ Capsicum

☐ Snow peas

☐ Avocados

☐ Bitter greens: dandelion leaf,chicory/witlof, endive,radicchio, etc.


STARCHY VEGETABLES SERVES/DAY

☐ Potatoes

☐ Sweet potato

☐ Pumpkin

☐ Carrot

☐ Beetroot

☐ Parsnip

☐ Taro

☐ Cassava, tapioca, sago


FRESH HERBS SERVES/DAY

☐ Basil, rosemary, coriander,dill, parsley, thyme, chives,spring onions, garlic,turmeric, onions


DRIED HERBS/ SEASONINGS SERVES/DAY

☐ Turmeric

☐ Coriander

☐ Cumin

☐ Paprika

☐ Nigella sativa

☐ Chili

☐ Pepper

☐ Salt





PROTEIN SERVES/WEEK

SMALL GOODS

☐ Ham, bacon, salami, chorizo,silverside, turkey


ANIMAL PROTEIN

☐ Red meat (e.g. beef, lamb,pork, kangaroo)

☐ Poultry (e.g. chicken, turkey,duck, eggs)

☐ Offal meats (e.g. liver, kidney,heart)


SEAFOOD

☐ Small and medium seafood:anchovies, butterfish, clams,crab, crawfish, croaker,flathead, flounder, haddock,hake, herring, Mackerel (clubonly), mullet, mussels,oysters, ocean search,pollock, salmon, sardines,scallops, sole (pacific), squid,tilapia, trough (freshwater),whiting, etc.

☐ Large fish: barramundi,bluefish, flake (shark),grouper, halibut, lobster,mackerel, mahi-mahi, marlin,monkfish, orange roughy,snapper, swordfish, sea bass,tuna (all types)


PROTEIN SERVES/WEEK

VEGETABLE PROTEIN

☐ Legumes (e.g. chickpeas,kidney beans, lentils, pintobeans, soy beans –whole)


NUTS

☐ Almonds, walnuts, brazilnuts, pecans, hazelnuts,peanuts


SEEDS

☐ Sunflower, sesame andpepitas seeds

☐ Flaxseeds, chia seeds


FERMENTED FOODS SERVES/DAY

☐ Kefir

☐ Kimchi

☐ Miso

☐ Natto

☐ Sauerkraut

☐ Tempeh

☐ Yoghurt





FATS AND OILS SERVES/WEEK

☐ Butter

☐ Olive oil

☐ Sesame oil

☐ Sunflower oil

☐ Rice bran oil

☐ Coconut oil

☐ Peanut oil

☐ Ghee

☐ Macadamia oil


GRAINS SERVES/WEEK

☐ Whole grain gluten (e.g.wheat, rye, oats, barley,pasta, spelt, kumut, burghul)

☐ Whole grain gluten free (e.g.brown rice, wild rice,buckwheat, quinoa,amaranth, millet, teff,polenta, etc.)

☐ Refined grains gluten andgluten free (e.g. crackers,pancakes, white breads andpasta, etc.)

☐ Nut or seed based crackersand/or breads

☐ Sweets (e.g. muffins, cakes,biscuits, desserts, etc.)


DAIRY OR DAIRY SUBSTITUTES SERVES/WEEK

☐ Cow (e.g. yoghurt, milk,cheese, ice-cream, etc.)

☐ Goats or sheep (e.g. yoghurt,milk, cheese, ice-cream, etc.)

☐ Soy (e.g. yoghurt, milk,cheese, ice-cream, etc.)

☐ Oat, almond or coconut (e.g.yoghurt, milk, cheese, ice-cream, etc.)


TAKE-AWAY FOODS / JUNK FOODS SERVES/WEEK

☐ McDonalds, KFC, HungryJacks, Subway, Kebabs, Fish& Chips, Thai, Sushi, Chinese,Indian, etc.

☐ Confectionery (e.g. chocolate,lollies)

☐ Soft drinks, fruit juices,energy drinks, ice tea, sportsdrink, etc.





BEVERAGES SERVES/DAY

☐ Water – how many cups/day(1 cup = approx. 250ml)

☐ Coffee (instant, expresso,percolated)

☐ Black tea

☐ Green tea

☐ Herbal tea (please specify)

☐ Fruit juice

☐ Vegetable juice


ALCOHOL SERVES/WEEK

☐ Wine

☐ Beer

☐ Spirits



Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counseling | Herbal

Medicine Mobile: 0431 221 253 | [email protected]| Fax: 02 6678 0424

PATIENT’S CONSENT

ConsentI hereby agree and understand that the treatment/advice given will include one or more of the following; dietary prescription, lifestyle prescription, nutritional/herbal/Homeopathic supplements, screening tests, physical examination and massage, which I knowingly and willingly consent to undergo of my own free will. At any time, I may withdraw my consent or reject any treatment or advice without prejudice from the practitioner.I understand that nutritional/herbal supplements are prescribed in a therapeutic fashion and if circumstances change (e.g. pregnancy, cessation/commencement of pharmaceutical drugs, etc.) from what was presented to the practitioner, I will notify the practitioner immediately, so treatment/advice can alter accordingly if required.

Privacy Policy:I consent to the gathering of my health information for the purpose of naturopathic care, case analysis and treatment. I understand that my health information is kept confidential, held in a secure way and for my practitioner’s access only. If there is to be sharing of information for the purpose of mentoring or professional supervision I authorise my practitioner to disclose anonymous information (i.e. no name, date of birth, contact information will be shared) related to my care and treatment to other practitioners for the purposes of clinical supervision and for the benefit of my care and treatment. A third party may lawfully request information if there is a risk of harm to others or myself. I have a right to access my files or have them forwarded to an accredited practitioner via written request. If access to health data poses a serious threat to a person’s health or life, it will be denied. I will provide my practitioner with up-to-date, complete and accurate health information for the purpose of complete naturopathic care. My practitioner will ensure these records are kept current. If I feel there are issues with privacy of my information I will first discuss with my practitioner and I have the right to make a complaint to the Information Commissioner.

Mental Health Consent:If you are consulting Therese regarding a mental health issue Therese will get in contact with your prescribing physician and other relevant medical professionals from the outset so that your care and management can be transparent and coordinated. If at any time Therese is concerned that you are a risk to yourself or to others, she will contact these relevant practitioners and if deemed necessary break confidence and contact your emergency contact person (family member or friend) as listed on the front of this form as well.

By signing this you acknowledge these to be conditions of being a patient of Therese Latta.




Emergency Contact/Crises:

I understand that Therese Latta Living Health Natural Medicine is not staffed 24 hours a day. In cases of emergency when immediate help and counsel is needed I understand the local resources available are Emergency Services (dial 000) and Lifeline 13 14 11.

SIGNATURE

DATE

Documents

Initial Consultation Health Details · DATE: NAME: DOB: ALLERGIES: Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counselling