All information provided is strictly confidential and used solely to help your practitioner design the most effective and personalised natural health protocol for you. Please answer as honestly and completely as possible.
01
Personal Information Basic identification & demographics
Physical Measurements
02
Chief Complaint & Health Goals Why are you here & what do you want to achieve?
Describe in the patient's own words whenever possible. The chief complaint sets the direction of the entire consultation.
Pain / Symptom Severity
0 — None
10 — Severe
Health Goals — What does healing look like for you?
03
Past & Current Medical History Diagnosed conditions, surgeries & hospitalisations
Do you smoke cigarettes or use tobacco?Include shisha, snuff, or chewing tobacco
Do you drink alcohol?Include beer, palm wine, spirits, ogogoro
Do you use recreational drugs or substances?
Do you use pain relievers (NSAIDs) frequently?e.g. Ibuprofen, Paracetamol, Aspirin — more than twice a week
Do you consume a lot of caffeine?e.g. More than 2 cups of coffee or tea per day
Stress & Emotional Wellbeing
0 — None
10 — Extreme
09
Women's Reproductive Health Complete only if applicable — skip if male
10
Recent Tests & Investigations Lab results, scans & medical reports
Please bring any recent lab results, blood tests, ultrasound reports, or doctor's notes to your consultation if available.
Test NameDateResult / FindingOrdered by
🌿 Practitioner's Assessment Notes — SEDDICON NATUROPATHIC HUB — For Official Use Only
11
Informed Consent & Declaration Please read carefully before signing
I understand and agree to the following:
1. The information I have provided is accurate and complete to the best of my knowledge.
2. Naturopathic health coaching is not a substitute for conventional medical care, and I will continue to follow the advice of any physician treating me for diagnosed medical conditions.
3. I consent to the collection and storage of this information for the purposes of my naturopathic health consultation.
4. All information shared in this consultation is strictly confidential and will not be disclosed to any third party without my express consent, except where required by law.
5. I understand that the recommendations made are based on naturopathic principles and are designed to support — not replace — medical treatment.
6. I am free to withdraw my consent and stop the consultation process at any time.