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BALANCED HEALTH NATURALLY ABN 34891705391 Jeannette Scapens (Adv. Dip. Naturopathy) 0439828669 info@balancedhealthnaturally.com.au Client details and history
Please complete this questionaire within 24 hours of your intial consult & with as much detail as possible as it helps to build a more accurate picture of your health.
Email address *
Confidential client intake form
Name *
Enter your full name
Address *
Street number, Name, Suburb, State, Postcode
Phone number *
Email *
Who referred you? *
Friend/family (name so I can thank them), website, Google, advertisement, Facebook, Instagram
Age *
Date of Birth (format month/day/year) *
MM
/
DD
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YYYY
Gender *
Height *
Weight *
Are you happy with your weight? *
Are you interested in the Metabolic Balance personalised nutrition program for wellness & weight loss which I offer? If so, have you read about it on my website or Metabolic Balance Australia website? Please have a look at my website if you haven't already. Please note that you must be willing to abstain from alcohol, processed foods & sugar for the phase 1 cleanse (2 days) & phase 2 strict phase (2 weeks) of the program for it to give the best results.
Family/living situation *
Who do you live with?
Children *
Do you have children? If yes, list their names and ages
Occupation and duties - include if you come into contact with chemicals at work *
Exercise and recreation - please list activities you undertake *
How much physical activity do you do? *
Daily average over 1 week
No physical activity
Marathon runner or equivalent
Have you lived or travelled outside of Australia? If so, when and did you get sick at all? *
Have you or your family experienced any major life changes? *
Please explain including rough time frame
Have you experienced any major losses in your life? If so, please comment *
Medications *
List of all current medications with doses and frequency
Have you ever been told that your blood pressure is high or low? Is it still an issue for you?
Do you take any vitamins, minerals, other supplements *
Please list
Have you had any surgery? Please include gastric banding/sleeve *
Please list including dates
Have you suffered any major accidents?
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Have you had any serious or long lasting illness?
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Past medical history - please explain further next to each ticked box *
Required
Family History
Mom
Dad
Brother
Sister
Grandparent
Child
Other relative
Cardiovascular disease (heart disease, stroke)
Diabetes
Cancer
Other
Depression
Do you have any metal implants/pacemaker/hearing aid? *
Tobacco use history
Currently high use
Current low-med use
Former use more than 6mo ago
No current or former use
Tobacco use
Alcohol use
Drug use 
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Tell me a little about your diet
Do you have any dietary restrictions? Do you follow a specific diet? Do you have any concerns about your diet? Do you consider your diet to be healthy? Do you crave anything in particular?
What things about your health are currently concerning you? *
When did you first experience these health concerns and was anything major going on in your life at the time? *
Have you tried any other treatments for these concerns? Please comment
Medical doctors, natural health practitioners, medication, supplements, etc
Have you experienced success with these approaches?
What other health professionals are you currently seeing?
Please list name and type of practitioner
In a few words, tell me about your sleep
Do you sleep well? Do you have trouble getting to sleep or staying asleep? Do you wake up tired or feeling refreshed? How many hours of sleep do you get each night?
What is your digestion like?
Do you suffer reflux, indigestion, heartburn? Are you constipated or do you experience diarrhoea? How often do you use your bowels? Do you have gas/wind? Do you have bloating? What else do I need to know about your digestion?
Do you have allergies?
Tell me about the symptoms, what causes your allergies, how badly the allergies affect you
If you are female, tell me about your hormones
Are you pre-menopausal, menopausal, or post-menopausal? If you still have periods, are they regular? Do you have pain with your periods? Do you suffer from PMS? What form of contraception are you using? Do you suffer from endometriosis, fibroids, ovarian cysts? What else do I need to know about your hormones?
What are your energy levels like?
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What are your stress levels like?
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Do you get sick often?
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What are your top 3 health goals? Are you committed to making the necessary changes to achieve them?
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