Online Naturopathic Consultation

This form is for you to use to request a consultation for yourself or on behalf of someone else - perhaps a child, friend, parent or loved one who would have difficulty doing it for themself. For this reason we have referred to the person who the consultation is for as a "patient" - this is simply to clarify the process of completing the form. In this form the use of the word "patient" does not infer anything whatsoever about any individual's legal or medical condition or situation.

I assure you that I treat this information with the same confidentiality and respect that I have for all my clients' information whether collected in my clinic or online. I will not use any of this information for any purpose other than to help me assess your health situation and to identify useful treatments or dietary regimes.

Trijntje Reilly

Please complete the form below as fully as you can,

Your Details Title Mr Miss Mrs Ms Dr First Name Last Name Gender please select Female Male E-mail Phone Mobile Address line 1 Address line 2 City or town State         Post Code  Country Birth date day     month     year  Patient´s Details First Name Last Name Gender please select Male Female Height    units used: please select Kilograms Pounds Stones Weight    units used: please select centimetres metres inches feet Birth date day     month     year  Blood Type unknown        A B O AB Patient´s Health History Details This information helps me develop a more accurate picture of the patient´s health and wellness history Describe any major illness the patient has suffered:  indicate if the patient has ever suffered from a major illness, hospitalisation or debilitating condition - including any childhood illnesses you are aware of. When done, you can use the TAB key to move to the next box. Has the patient ever had any broken bones: Describe what bones were broken and at what age Has the patient ever had any organs removed: Describe what organs were removed and at what age Patient´s Current situation This information helps me develop a picture of the patient´s current state of wellness. All questions refer to the patient. Describe any current illness the patient is suffering: indicate what illnesses the patient is currently suffering. Describe all current symptoms the patient is currently suffering: indicate what symptoms the patient is currently suffering Describe when the symptoms are worse: indicate what times of the day and night the symptoms are at their worst How would you describe the patient’s Energy level: How would you describe the patient’s Stress level: Please describe the patient’s current emotional state: Indicate what emotions and feelings the patient is mainly experiencing - feel free to go into detail Please describe the patient’s current mental state: Indicate what thoughts and mental states the patient is mainly experiencing Please describe any aches the patient is currently experiencing: Identify the location of any aches and their nature eg sharp, dull, intermittent, steady, mild, severe, pulsating Please describe any body pains the patient is currently experiencing: Identify the location of any pains and their nature eg dull, sharp, constant, intermittent, severe... Please describe any known allergies, their causes and symptoms: Indicate the foods or drugs which produce the allergy and describe the allergy symptoms or how they affect the patient Please indicate what the patient’ Bowel Movements are like: Indicate as best you can eg: Constipated, Diarrhea, Normal Describe any mucus discharge the patient is experiencing: If the patient is experiencing any mucus discharge indicate where and its nature eg thick, watery, yellow, white, clear, with blood Please describe the patient’s diet in detail: What does the patient normally eat throughout the day - include meals, snacks and drinks Please describe what exercise (if any) the patient is doing regularly: What activity the patient regularly undertakes - at work and elsewhere eg gym, walking, gardening - and for how long. Describe any Prescribed Medications the patient is currently taking: List any prescribed medications the patient is currently taking - including the name of the medication and the daily dosage Describe any Vitamins and Mineral supplements the patient is currently taking: List any vitamin or mineral supplements the patient is currently taking - including the daily dosage Describe any Herbal or Homoeopathic Medicines the patient is currently taking: Please list the herbal and/or homeopathic medicines and their dosages which the patient is currently taking on a regular basis Describe any therapeutic treatment the patient is currently undergoing: Please tell me what therapy or therapies the patient is currently undergoing and anything else you can add about their duration, frequency etc. Please add any information here, in your own words, any other information which you feel is relevant: Please tell me anything else which you think might be relevant to the patient's situation or condition. Payment Details   Do you want extended support? no thankyou - just the consultation yes please - I want 6 months ongoing email-based support   Total Payment Amount: AUD$ Credit Card details:- Credit Card type please select card type Visa Mastercard Card Number CVC Number the number on the back of your card how to find your CVC number. Name on Card Expiry Date Month select 01 02 03 04 05 06 07 08 09 10 11 12     Year select 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Maximum Authorised Debit:  AUD$ Send your request now

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