Initial Consultation Form

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Initial Consultation Form
Initial Consultation Form
‘
Client name: _________________________________________
Date: _____________________
Presenting complaint review
Nature, onset, perceived cause, progression, associated symptoms, better/worse for, Red flags, other complaints:
Goals:
Nutrition
Food diary Overview
Meal composition (macronutrients), possible deficiencies, pattern of eating:
Method of cooking
% organic
% homemade
Packet sauces used
Awareness of additives
Dietary considerations
Foods avoided/disliked
How do they eat?
Weekly food budget?
Frequency eating out
and type
Cravings – type, timing
and surrender to
Fluid intake
Skip meals
Body Systems
Digestive – appetite, reflux/burning/gnawing after meals, discomfort after eating, bloating, urgency,
cramping, wind, sleepy after meals, blood with stool – bright/dark, pain (location/type) , nausea
Integumentary - eczema ( hot, dry, red, inflamed, location, raw, itchy), psoriasis (scaly, red, inflamed,
location) , acne (location, white pustules, red/deep, cyclic) scars, boils, flushing, sweats, cracks,
itching, bleeding gums, cracked lips, sunburn, dry/oily
Respiratory – difficulty breathing/asthma/constriction, chest pain, sputum (colour), shortness of breath,
wheezing, cough
Urinary – Bladder infections (burning/ blood with urination), flow of urine, complete urination, pain,
kidney infections (lower back pain/blood in urine), fluid retention (location), incontinence
Cardiovascular – anaemia (easy bruising, pale, breathless, fatigue, frequent infections), varicose veins
(pain), high or low blood pressure, palpitations, chest pain, cholesterol, cold extremities, bleeding/
hemorrhages (nose bleeds), broken capillaries, burst blood vessels
Musculoskeletal – cramps, restless legs, growing pain, areas of tension, repetitive strains, arthritis,
injuries, pain, stiffness, tendonitis, bursitis, twitches, dental health/history
Lymphatic / Immune – previous illnesses, glandular fever (severity), flu vaccine, freq of colds / flu per
year, heal quickly, hay fever / sinus (blocked nose, itchy eyes, tickly throat, pain in sinus, runny), cold
sores, swollen glands (location, hard/soft, moveable, pain) , frequent infections
Reproductive – Women – Sexual function, STDs, # of
pregnancies, difficulty getting pregnant, last menstrual cycle,
length of cycle, frequency of cycle, colour, flow, duration, clots,
cramping/pain, PMS (irritability, sore breasts, sore back,
cravings), noted changes in cycle with age, noted discharge,
itching, odour, thrush
Men – sexual function, STDs,
impotence, discharge, pain, blood, low
testosterone (loss of muscle, low
energy, low libido, decreased strength)
Nervous – insomnia, restlessness, irritability, depression, anxiety, teeth grinding, ability to tolerate
stress, mouth ulcers, vision, hearing, smell, taste
Endocrine – hypothyroid (cold hands/feet, dry/itchy skin, dry/thin hair, constipation, brittle nails, poor
concentration, fatique) hyperthyroid (fast beating heart, bulging eyes, loose bowel motions, fatigue,
anxiety), blood sugar dysfunction (intense hunger, nervousness/confusion, trembling, palpitations,
anxiety/irritability, poor concentration, dry mouth, thirst, frequent urination, irritable without food, blurry
vision, dry/itchy skin, poor eyesight, yeast infections, numb tingling feet) hypoadrenia – (tired upon
waking, insomnia, excessive fatigue, craving salt, overwhelmed, poor concentration, low immunity,
depression)
Emotional tendencies – cope well on a daily basis, thriving/growing, satisfied with life, happy, supported,
feel able to change things if not
Client Consent
I, __________________________________, give consent for my health information to be documented
and appropriate physical examinations and assessments to be performed. I understand that following
the consultation a treatment plan will be created for me after agreement between myself and the
student practitioner. I will give the practitioner all personal information needed to perform a safe and
successful treatment. I am aware that both practitioner and I have the right to stop the consultation
procedure and / or treatment at any time.
Client Signature: ________________________________________________________________
Student Practitioner Signature: ____________________________________________________
Clinical Assessments
Blood Pressure
- Sitting
- Standing
Respiratory Rate
Zinc Taste
1
2
3
4
Height
Pulse
Weight
Temperature
BMI
Blood Type
Key Note
Endocrine body type
Body Language
Facial Signs
Nail Signs
Colours, lines, marking, scars, sunken, age spots
Pitting, ridging, white spots, lines, marks, colour, capillary
refill, cuticles, growth, strength
Tongue
Colour
Size/Shape
Coating
Tremor
Markings
Iridology/Sclerology
Other Physical Assessments
Lymph, Thyroid, Abdominal, Melanoma, Phalens, skin scratch, PPRT
Evaluation Summary
Possible causes for complaint
Treatment Focus
Overall approach of treatment
Treatment Plan
Specific and individualized treatment
Hb/ Flower essence/ Supplements recommended:
Nutrition advice:
Lifestyle Advice:
Handouts Given:
Referral to:
Self Reflection
Client take-home shopping list
Shopping list:
Nutritional aspects to integrate:
Lifestyle techniques to look into:
Prescriptive remedy instructions:
Please feel free to call me and discuss anything that may occur to do with your presenting complaint. I
will have your thorough treatment plan ready in a day or two and will call you to discuss.

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