New Patient History Questionnaire

New Patient
History Questionnaire

Please complete this New Patient History Questionnaire if you have not had a consultation with Jenny Blondel, Naturopath before.

Once this is submitted you will be asked to may a payment to Jenny Blondel via PayPal, your secure way to pay online.

Jenny will then contact you to schedule your online consultation.

FIRST CONSULTATION FEE: (?)

New Patient
History Questionnaire

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

"SKYPE" Name*
"SKYPE" Name*

E-mail Address*
E-mail Address*

Confirm E-mail Address*
Confirm E-mail Address*

Preferred Date For Your Consultation*
Preferred Date For Your Consultation*

Alternate Date*
Alternate Date*

Preferred Time For Your Consultation (am/pm)*
Preferred Time For Your Consultation (am/pm)*

Gender*
Gender*

	Female
	Male

Height

Weight*
Weight*

Age*
Age*

Do you use smoke?*
Do you use smoke?*

	No
	Yes

How often & how much?

Do you drink alcohol?*
Do you drink alcohol?*

	No
	Yes

How often & how much?

Do you have caffeine?*
Do you have caffeine?*

	No
	Yes

How often & how much?

ALLERGIES*
ALLERGIES*

	No known allergies
	Food Allergies
	Medication Allergies
	Pet Allergies
	Seasonal Pollen Allergies

Other Alllergies - Please List

Please list food allergies

Please list medication allergies

NUTRITIONAL/NATURAL SUPPLEMENTS: Which products are you using?**
NUTRITIONAL/NATURAL SUPPLEMENTS: Which products are you using?**

	None
	Vitamins
	Minerals
	Herbs
	Enzymes

Please list supplements

MEDICAL CONDITIONS/DISEASES: *
MEDICAL CONDITIONS/DISEASES: *

	None
	Heart disease
	High cholesterol
	High blood pressure
	Cancer
	Ulcers (stomach, oesophagus)
	Thyroid problems
	Lung disease or asthma
	Blood clotting problems
	Arthritis or joint problems
	Diabetes
	Depression
	Epilepsy
	Headaches/migraines
	Eye disease (glaucoma, etc)
	Other

Please list other

Please check if you take any of these prescribed medications

	Laxatives
	Oral Contraceptive Pill
	HRT
	Sleeping aids
	Antacids
	Anti-depressants
	Analgesics (pain relief)
	Aspirin
	Warfarin
	Cholesterol lowering drugs
	Other

Please list Current Prescription Medications & Dosage

Please check if you have a family history of the following*
Please check if you have a family history of the following*

	Asthma
	Cancer
	Diabetes
	Heart Disease
	Osteoporosis

List family member(s)

How many pregnancies have you had?* *
How many pregnancies have you had?* *

How many children?* *
How many children?* *

ARE YOU EXPERIENCING: Pre-Menstrual Syndrome*
ARE YOU EXPERIENCING: Pre-Menstrual Syndrome*

Lumpy Breasts?*
Lumpy Breasts?*

Weight Gain?*
Weight Gain?*

Irregular Menses?*
Irregular Menses?*

Hot Flashes/Flushes?*
Hot Flashes/Flushes?*

Dry Skin/Hair?*
Dry Skin/Hair?*

Anxiety?*
Anxiety?*

Depression?*
Depression?*

Night Sweats?* *
Night Sweats?* *

Vaginal Dryness?*
Vaginal Dryness?*

Headaches?*
Headaches?*

Irritability?*
Irritability?*

Mood Swings?*
Mood Swings?*

Breast Tenderness?*
Breast Tenderness?*

Sleep Disturbances?*
Sleep Disturbances?*

Cramps?*
Cramps?*

Fluid Retention?*
Fluid Retention?*

Breakthrough Bleeding?*
Breakthrough Bleeding?*

Fatigue?* *
Fatigue?* *

Loss of Memory?*
Loss of Memory?*

Bladder Symptoms?*
Bladder Symptoms?*

Arthritis/Joint Pain?*
Arthritis/Joint Pain?*

Decreased Sex Drive?*
Decreased Sex Drive?*

Hair Loss?*
Hair Loss?*

BLOOD TESTS - Please check if you have recent results for any of the following:*
BLOOD TESTS - Please check if you have recent results for any of the following:*


	No recent blood tests
	Haemoglobin
	Thyroid Stimulating Hormone (TSH)
	Follicle Stimulating Hormone (FSH)
	Luteinising Hormone (LH)
	Estradiol(E2)
	Progesterone
	Free Testosterone
	Testosterone
	DHEAS
	Cholesterol (total)
	HDL - Cholesterol
	LDL - Cholesterol
	Blood Sugar Levels (BSL)

Please list the results of your blood tests here: *
Please list the results of your blood tests here: *

Do you have any questions about Naturopathic treatment for Hormone Imbalances? (Please list)

Do you have any questions about any other non-related conditions?

Please enter the word that you see below.