NATURAL THERAPIES - Consultation Form Date of Consultation: Mh om —t ¢ —___ ‘Student Practitioner Nam Clinic Supervisor Name: ‘TYPE OF NATURAL THERAPIES CONSULTATION (© Naturopathy Nutrition O Herbal Medicine TABLE OF CONTENT PRESENTING SYMPTOMS: SYSTEMS REVIEW... DIGESTIVE sysTeN ‘CARDIO-VASCULAR SYSTEM. RESPIRATORY SYSTEM. e i NERVOUS/SENSORY and EMOTIONAL/PSYCHOLOGICAL SYSTEM... INTEGUMENTARY/SKIN.... ENDOCRINE SYSTEM... URINARY SYSTEM... : MUSCULAR- / SKELETAL SYSTEM... IMMUNE SYSTEM... FEMALE REPRODUCTIVE SYSTEM. FAMILY MEDICAL HISTORY. (GENERAL HEALTH HISTORY / FACTORS. REGULAR DIET 11 MEDICATION / SUPPLEMENTS/ SMOKING / ALCOHOL eaten RECREATIONAL SUBSTANCE USE R PHYSICAL EXAMINATIONS. B IRIS AND SCLERA / IRIDOLOGY. B ‘TREATMENT PROTOCOL, 14 ‘TREATMENT PROTOCOL continued. 1S sa as aromas rience: AEClinic ~ Patient Form ACNT PRESENTING SYMPTOMS: ‘Questions: How can help you? What brings you to the clinic today? What are you hoping to achieve from our consultation today? Sins nd Spon: : indain Fait Gouin around she. band « Chawsyes (Osh: toenioe DvBuqd hang Allowed dsGmnbort reread He Get onset Re cluwent beodade for tHe Past 2-3 errs pecravatingfactors SHVESS + LaproP rawr Duration mary (ast 1G%Z owes Frequency 2-9 times Ov | anetertng cons ON GAleyeSS (Raaddol ov Nyvoken / Sek | | coneamtantoaor- pc le om! Ghowiebr StiEness Poor Conceatvorhon | ausity deep dull cule | severity 5//Q History of Presenting Symptoms [Wwar HAPPENING IN Life, Tiseuine, Procressiow ETC} iW: ae asuna messores AEACNT Clinic Patient Form SYSTEMS REVIEW (start with those most relevant to the Presenting Symptoms!) DIGESTIVE SYSTEM MOUTH: [ULCERS, BLEEDING GUMS, 20 BREATH, TASTE, CRACKED LIPS, TEETH PROBLEMS OR OTHER] Jy lcers when Stvescel problem ith Hate Amalgam Filings: Ces?No___ HowMany:_- UPPER DIGESTION: [HUNGER, HEARTBURN/INDIGESTION, BURPING/BELCHING, NAUSEA, BLOATING, VOMITING aa 4 Jeet Problem: hot Somethin) new, LOWER DIGESTION: [FLATULENCE, CONSTIPATION/DIARRHOEA, HAEMORRHOIDS, CRAMPING, BLOATING, PAIN, (LOCATION/ SENSATION), JAUNDICE OR HEPATITIS, OTHER SYMPTOMS} = wos tot He Mee wouter bowed mortimne s = mgt fation Once Creer) week, nore Groug He tine be fake We anqiories, Por lewloele. BOWEL HABITS: [FREQUENCY, TYPE, COLOUR, PAIN, CRAMPING, ODOUR, MUCOUS, 81000, DIARRHOEA, ‘CONSTIPATION, COMPLETE, FLOAT, UNDIGESTED FOOD] - ofa sionorl blog fing. - Lalines -lilee inctige sion ~ Stool type befswer 2-4 6r Stool hogClinic Patient Form ACNT ‘CARDIO-VASCULAR SYSTEM Fenn (peas sen Pc Ciesla al PaO ORS Se enon ees aie Omnia One| ni GENERAL CIRCULATION: [Col HANDS OR Feet, FLUID RETENTION, SWOLLEN ANKLES, NUMBNESS OR TINGLING, VARICOSE OR SPIDER VEINS, HOT FLUSHES, LEG CRAMPS, OTHER] ni RESPIRATORY SYSTEM. UPPER/NOSE: (SINUSITIS, HAYFEVER, COLDS, NOSE BLEEDS, NASAL STUFFINESS, POST NASAL DRIP] vill CHEST & RESPIRATORY: [ASTHIA, WHEEZING, SHORTNESS OF BREATH, SPUTUM, COUGH, BRONCHITIS, PNEUMONIA, EMPHYSEMA, PLEURISY/TUBERCULOSIS, OTHER) ua ress vn teensy 19528Clinic Patient Form ACNT NERVOUS/SENSORY and EMOTIONAL/PSYCHOLOGICAL SYSTEM HEAD: (HEADACHES, MIGRAINES, TENSION, VERTIGO/DIZZINESS, NECK PAIN, LIGHT HEADED, OTHER | Neck PON Lt tant Shoatdoy s EVES: (@lAsSB5/CONTACTS, ‘TIRED/SORE, WATERY, REDNESS/ITCHING, DOUBLE VISION, BLURRED VISION, GLAUCOMA/CATARACTS, OTHER | 8 yen aho - Short sicled: EARS: [Ear INFECTIONS, DEAFNESS, DISCHARGE, TINNITUS/RINGING, EARACHES] Nd NEUROLOGICAL: [BLACK OUTS, SEIZURES, PARALYSIS, LOSS OF SENSATION, TREMORS, DIZZINESS) yk EMOTIONAL/PSYCHOLOGICAL: [DsPRESSION, ANKIETY, PHOBIAS, PANIC ATTACKS, MOOD CHANGES] nitl INTEGUMENTARY/SKIN {Da¥/Owy, Piwpces, ACNE, PsoAIASIs/EczeMa/DERMATITIS, FUNGAL INFECTIONS, COLO SORES, ALOPECIA, Greving, OTHER] ~Childhood (Cama SeasiHive skin tyty seme With Bott Combinabion of 9)(4 ancl Liq chron fey vese aol reluad.” i uum nemo: AEClinic Patient Form ACNT ENDOCRINE SYSTEM THPA, THRO (HEAT/COLD, SWEATING) , DIABETES ( THIRST, HUNGER, POLYURIA), HYPOGLYCAEMIA, WEIGHT {eaun/toss, Ceavins, FATIGUE] N= Sone Latigne Oey long doy, Recover duwrny weelcershs URINARY SYSTEM [UTI’s on Crsriis, Pain, NOCTURIA, STONES, FREQUENCY/URGENCY, BURNING, INCONTINENCE, DRIBBLE] Nis MUSCULAR- / SKELETAL SYSTEM TW, Pan, Sr, Sein ART, BREN BONES, Canes] Ge } — Sone Himes le) Crames 4 dvins He clan vly/le i wid bot flee 5 bommgliin ow Wotleing , a ~desnot do ChdvOes. wenscanesiores OE &Clinic ~ Patient Form ACNT IMMUNE SYSTEM. TNFECTONS, HeALNG Tv, GLANDS, SWELLING, FREQUENCY OF WFECTONS] No inbakon noes 7 last interior last Beary sone tvcot - |a tel feeling Letigued olurint) week . MALE REPRODUCTIVE SYSTEM [PROSTRATE PROBLEMS; INFECTIONS; DISCHARGES; STD'S, PAINFUL/INTERRUPTED URINATION, STD PROTECTION, ‘CONTRACEPTION, ERECTION PROBLEMS, LISID0] Nall Sexually Active:( Yes)/ No Libido: Poor / Good /fNo Concerns ) STD Protection: Contraception: Conclems nameacreesiores OEBe eet eee eee ee Clinic Patient Form ACNT FEMALE REPRODUCTIVE SYSTEM Menstrual Cycle : [Recuan/imrecutan, LENGTH, DURATION OF MENSES; HEAWY/UGHT; COLOUR; SPOTTING: ain /CRAMPS; PREMENSTRUAL SYMPTOMS [PHYSICAL/EMOTIONAL}; MENOPAUSE] Menarche: [How 0.0] ‘pido: Poor / Good / No Concerns Sexually Active: Yes/No ‘Method of Contraception: Pregnancies: (@RTHs; TERWINATIONS; MISCARRIAGES; DFFICULTY FALLING PREGNAT; COMPLICATIONS — HYPERTENSION; iaseres; peuveny) Infections: {rinusi;cANDIOA; Pb; DISCHARGES; HERPES; WARTS; SORENESS; ORYMESS STO'S] | Last Pap Smear: tox] / / Result: Regular breast exams: Yes / No Last Mammogram: (exe) / Result: site somrunas enesaotes: AElinc - Patient For ACNT PAST MEDICAL HISTORY Childhood Illnesses or Conditions: (w.esaes;ess nezcnons; mesis; mms ec] AW CALwed VACGRotion done: CGvamnin Eid Cords kone, + Chicleen bon one ea Common, ‘Vaccinations: frease nex nic aporomnite 904] EB a Measles ~ Mumps Rubella Flu smallpox Tetanus o Polio OD hepatitis 8 Overseas Travel {wnes, yen, anrvsccwenons] nik Adult Illnesses or Conditions: {asa nacyan, aber; oenTEWion; HEPATS; MM, MENTAL HEALTH Ec] il Operations: [russe raovoe sues ors micas cares] Nill How Often Use Antibiotics?: Gi1(@ Cc Ypeow What for?: (econ Last Time: Date: /ac} Yecur Do You Always Finish the Course?: Yes / No (Sometimes) Other Health Practitioner/s? (e¢, chiro/osteo/Pmsio/Acupunctare/ineslokegt/CounseBor/Psychlogs)? Dentot- No Pegular EP Blood Tests: DATE OF LAST: Iron TSH wee Other Vitamin 0 ut Cholesterol FAMILY MEDICAL HISTORY Monee: Mi Dromes , Ci Cele Of CSS. Oe eas Farner: wy, ferlerSion » Prrysad GRANDPARENTS: MATERNAL PATERNAL Granomoruer | \)/' Cun Del HRW il NO euouv WS Pfucrt protic Granorarnen | D4 for Pension Passed ayer br Om bork seunes: Bo tev; Gr Cholsevol mediCations Yourcunoren: Nil 3G ley! ANE amd Zen nara racoiores AEClinic Patient Form ACNT GENERAL HEALTH HISTORY / FACTORS In general how would you describe your health? Any recent changes?: (sume we, Econ mess, ANY CLOTHES HET HT MHTER OF LOSER HAN MORE. Wea, ANOUE, EER] Susy moo 4 He Hve P Finedtness. dui) Ye cools How would you rate your energy levels (out of 10)? /10—_(A=No energy, 10-abundantenereyd Sleep: {wien 7 sco; ow tons; TROUBLE FALING ALE; DEEN/UGNT/UNDISTUREED; WAKE OURMG THE AGH NOCTUR WAKE SRESHED; REANS~ 000/840 RECURRNG, SNORNG] i leere, NO trowlyle Lamingy a steeP. Avoroe > 5-6 hours, - wake vp owing orgie at 3,001mm +? S ad he Goback ty Slee’. peel nebeshed jee next dou, Exercise: [pow orrev0o vousxenose—rit oF exert} He does nof do aA Pe SR REWCIge- Wer Nhe Wwalles every doy ho Werle ad Univers,» fotal| UG mines. ras tuialeing ot Jong gyn GENERAL QUALITY OF LIFE, STRESS LEVELS etc. Wore? worlEs at woowots—» Sone Ser Suburb Llere Le Ve. ory Stressed (ody RELATIONSHIPS/FAMILY?: Tans with Wis tay ter. NO mudh Social Che» dag Mo bis busy select. Feat 4 WE iA RMww ZeoUlad!- How would you rate your current stress levels? ¥ sro (1=No stress, 10= extreme) Is there anything else you would like me to know that we haven't already discussed?: No naruanswemores: AECClinic Patient Form ANT REGULAR DIET Breakfast: Two Petes Ef thaole nent toa One with Goff cless grct one berth yan. t black Fea teulle Prerced 284 wnat whole toast Morning Tea: Muesli har ond pigict MAME te fasta Yoffee with tus ts Saga Lunch usually Scie meal br Bat um ze Liiclen Sandvich- Afternoon Tea: segond Cofhe Ske JOY: Goro! O02 Seng OF byuit (Panana ov app te De easy gd one meal Uke Chrcleny beeF ov fin with Lemetables Camies oF Ce. Supper: = tac Hoe wits Pree OL Chocolat ‘Are there foods you crave? Nil Are there foods you avoid? jy very > (ales ; Sense balew4 Erol ‘Any foods or substances that you believe aggravate or don’t agree with you? How much of the following would you have per day?: Sugar: tbrown/white] pg) D bP Milk: ) wiHa blacle ka Tea: tee’) | place fea 2 Herbal Teas: yp ¢ (1 Coffee: itvoer > Soft Drinks/Cordials: ¢ Gonice glnses ley Fruit Juice: “ Filtered Water: aye U Tap water |-2 Glasses ou =Clinic~ Patient Form ACNT MEDICATION / SUPPLEMENTS/ SMOKING / ALCOHOL Current Medication - including the Pill. || Current Supplements: (resse moe txsow; Dosace [ruse moeate Reason: bose & FREQUENCY Arecauencr] Nuvotern TAvane- 2 tablct. 2 -a Hees ni wweek Povacedemol . 1-2 tHe lets adays Do You Smoke?: Yes{NO) How many: Aleohol?: (f€5/No How much: { Type of Alcohol: RECREATIONAL SUBSTANCE USE Current [wocareoossse &FReoutner] Past: moxare cosace & neon] Ni \l Exposure to farm or industry chemicals e.g. painting, printing, cleaning, beauty? (wie: re Ul Treatment Considerations (Experience of taking supplements wilingness to take and invez, Le. Complioney, Sinanca, Taste). Are they wanting to or wiling to take a supplement/herbal mixturefother from this consultation? mane nanan nenaresr AE s weClinic Patient Form ACNT PHYSICAL EXAMINATIONS Nails: Tongue: C | Splitting uM a Sm} a ie feo He O | Brittle al book CO | nail Biter OF | Ridging Pole pin 1G i Other: wit, SM beHl4 Sibls Blood Pressure. Weight & Height sitting: L0/ $0 mmVloy Weight Current (ke): 40, Standing: Goal Weight (kg): —— Helght: |.) GcmB8Ml: 26 SalivaTest yj /( | Zinc Tally wilt ) Other physical observations? all IRIS AND SCLERA / IRIDOLOGY Nill nll The iris Image — Right Eye fhooxmne ar anorusnpenson’s iG ve) The Iris Image — Left Eye (.ooane ar aware eS FE) wenmarenens OE :‘esmiEnr PROTOCOL ‘Renmaacapein | aaltaalel me oma — Vi le F v date rains 4 MMM A eBay petiow Ue no, raid Solon 4 weeks Unprove Ses [pela on | Dee? Ss le& Stressed antenna pee, — fRmerVe | OMe E | gee trong st eee basicly, improve Reset Ovo cednipahien MOM diane 2 wreies diet sore Yes Golors uy (festa ue ae ae Shressed | should Chin, PAG god cecciali singh 04" ae wellbeing ravens resus AEClinic Patient Form ‘TREATMENT PROTOCOL continued... HERBAL MEDICINE: all DIETARY CHANGES: Pp water Consume hon Y Caffe intatce include Fire With food: include wnch weal antag fu das with Podin ad gatads BUSH/BACH FLOWERS: [NUTRITIONAL SUPPLEMENTS: may oPptcell — Sey manatinet flan ~ TRend! Haw ynolen Cum mi 1 A8@ abeew \woaic Seat vase after Lunch. LIFESTYLE CONSIDERATIONS: HOMOEOPATHIC REMEDY: = mGrd Sieh) weeds — Gwy @ wate vole ave Ot OM free ~ pew relakabun echvedper DIAGNOSTIC TESTING: ore wt awClinic~ Patient Form Other Notes: Considerations/Points for Follow Up Consultation: " nano rensores AE i w ACNTWELLBEfNG CENTAE Client Name: (First Name & Surname) Student Practitioner: 7 ai) ona Te Nod Supplement Nome/ Herbal | Breakfast Lunch Dinner Before Bed Formula oe | we] ar | oe | we] ar | or [we | AF | Oretherinatuctions mary OPH cell Ie fh Key: BF = Before Food WF = With Food AF = After Food Breakfast Suggestions: add ey S to Te brealcFast+ * 1mTHINK —-———-~ | WELLBEFNG CENTRE Lunch Suggestions: pov LC @_ sondwrch Os WOW - Or aU avin ahi vely bey van /sutad for lunch. Try wot to ship lunch Dinner Suggestions: .(winge Cie Vit food. Snack Suggestions: vaw nurs fo te Fruke Youg wt with \eope ter ble Shrcles Other Suggestions: Book appsiatunet will op tou etrist Please Note: ‘The Australasian College of Natural Therapies does not recommend patients to cease their prescribed medications WITHOUT prior consultation with their medical practitioners. wren renwes AETHINK ay | WELLBEFNG CENTAE | » 19-3. 2016 ______ —SulENT RECOMMENDATIONS = Increase wake _ ind ical a GN shears sade ~ Pa SWwt COM (Ay rerey Joottle ws ka yeti are le sow —reolela—CaPing vabovtce ey hole. wo mo. more 2 o0lth4, -—plerye boo [<_ age’ mura Pomatis = ladlucke bento spacde in dcek