Naturopathic Case History Details

/ Three Doors Health
Clinic
Naturopath, Herbalist and Bio-resonance Therapist / Susie Oosthuizen
262 Kangaroo Gully Road
BELLBOWRIE QLD 4070
Mobile: 0438 787 659

NATUROPATHIC CASE HISTORY DETAILS

Name______

DOB______/______/______

Address______

Phone No: Home)______(Mobile)______Work______

Email address______

Emergency Contact Name & Ph.______

Doctor’s Name & Address______

Private Health Fund Name______

Current Occupation/s-(include Paid & Unpaid work)______

Hrs Per week______Responsibilities/Duties______

Past Employment- How long? Type of Work.Chemical Exposure?Other?

______

What are your major stresses in life?

______

Relationship Status- married, de facto, divorced, single, separated- how long?

______

Children- No of own children, step children or other? Other children in your care?

______

Living/Family Situation- who do you live with, what is this like for you? Support?

______

Any family difficulties?______

Education History & Qualifications/Current Studies-______

Financial Responsibilities & strains (present & past)______

______

Hobbies/______

______

Exercise Routine______

______

PRESENTING COMPLAINT

What is it that you are seeking treatment for?______

______

What symptoms are you currently experiencing?______

______

HEALTH HISTORY - Other current and Past Health Issues

Please list all the diagnosed medical conditions you have or have had in the past, including operations, no of births including miscarriages, acute and chronic conditions including any emotional or mental health issues:

Is there anything else that troubles you in any other part of the body?

CONDITION / ILLNESS / HOW & WHEN DID IT START / MEDICATIIONS / DETAILS

Hospital visits/Previous Operations/ Surgery/When______

______

Medical Tests/ Investigations requested/had in the past or recently______

______

Your Birth (Details of your own birth/adoption/).Any significant events/accidents/trauma that occurred toyou while in utero or to your mother during her pregnancy and giving or after birth that you know of.

______

What number child are you in the family?______

Childhood Illnesses-______

______

Infectious Diseases-______

______

Serious Accidents/Traumatic Events eg grief, separation, car accidents, loss of family/friend, financial,emotional etc__

______

Overseas Travel & Illnesses______

______

FAMILY HISTORY Illnesses in your family members Examples: Ca, BP problems, Diabetes, Stroke,

Kidney Disease, Arthritis, Cardiovascular Disease, Mental Illnesses, Genetic Disorders- strong incidence or raredisorder etc

Relative / Health Conditions they have / Died at Age / Cause of Death
Your Mother
Your Mother’s Mother
Your Mother’s Father
Your Father
Your Father’s Mother
Your Father’s Father
Your own Brothers/Sisters

Medications- What medications do you use, that have been prescribed for you? List below

CURRENT MEDICATIONS OR NATURAL SUPPLEMENTS YOU ARE TAKING

MEDICATION/SUPPLEMENT / USED FOR / DOSAGE PER DAY

Are your meds being reviewed regularly by your doctor?______

Compliance with medications. Is it difficult or easy to take medications as prescribed? ______

______

Do you find it easier to take tablets, powders or liquid medications?______

Adverse/Allergic Reactions- to anything/medications/food etc in the past______

______

Vaccinations Please list all vaccinations that you have had and any adverse reactions______

______

Chemical exposure-Previous or Current Exposure to Toxic Chemicals/Pollutants/Paints______

______

Smoker- How many per day /week. How many years have you smoked?______

______

Alcohol What type, how much, how often? How much alcohol can you have?______

______

Recreational Drug Use- What & how often do you use? Past Use?______

______

Anything else you have used or taken in the past?Eg: Diet Pills, Energy supplements, vitamins etc

______

Do you drink any of the following (Please Circle) Coffee, Black Tea, , Herbal Tea , Green Tea , Decaf

How Many Cups per day?______Do you take milk in tea and coffee ______

Sugar or Artificial Sweeteners in tea and coffee______How many per cup?______

Soft Drinks- How many per day?______Type ( diet, guarana, red bull etc)______

Water Daily Intake______

Alcohol(Circle correct one)

None One per day Two per day Three to five per day More than 5 per day

List the favourite foods that you like to treat yourself to.

______

What type of foods do you choose to eat for snacks between meals?

______

What times of the day are you most likely to snack or pick at foods?

______

What types of foods do you like to have when you eat out or have take-away meals?

______

How many meals per week would you eat that are not prepared in the home (incl. breakfast and lunches)? (circle)

None 1-2 meals per week 2-5 meal per week 5-8 meals per week 8 or more per week

Please list any food intolerance or food allergies?

______

YOUR TYPICAL DIET

MEAL / FOOD / DRINKS
Breakfast
Mid Morning Snacks
Lunch
Afternoon Snack
Dinner
Late Night
Snack

Food l crave

______

Foods l avoid

______

DO YOU OR HAVE YOU EXPERIENCED ANY OF THE FOLLOWING, PLEASE LIST

HEADEG:
Pain, Headaches, Migraines, Vision, Scalp,
Hair , Other
UPPER RESPIRATORY
Sinus,Ear, Nose, Throat, Glands, Cold, Flu,
Mucus, Discharge, Pain
LOWER RESPIRATORY
Eg: Lungs, Breathing, Wheezing, Shortness of
Breath, Coughing, Expectoration, Chest Pain,
Pneumonia, TB, Fevers, Night Sweats, Chest XRay,
Bleeding or discharge from breasts/lumps
CARDIAC
Blood Pressure, Heart Attack, Rheumatic Fever,
Cold extremities, Numbness, Tingling, Shortness
of Breath on exertion, or wakes you from sleep,
Pain/Pressure in chest, neck, arms, Ankle
swelling, Irregular or fast heart beat, Pain in
legs with exercise
UPPER DIGESTIVE
Mouth, teeth, Stomach, Oesophagus, Liver,
Burping, Reflux, Indigestion, Pain, Bloating,
Difficulty Swallowing, Taste, tooth Decay,
Appetite, Heartburn, Abdominal Pain, Cravings,
Aversions, Thirst, No Thirst
LOWER DIGESTIVE
Bowels & Stools- Colour, Consistency, Shape,
Size, Freq, Urge, Smell, Mucus, undigested
Food, Blood, Constipation, Diarrhoea, Abdo
pain, Anorectal pain, cramping, gas, bloating
Hepatitis, Peptic ulcers, Colitis.
How many motions per day?
URINARY SYSTEM
Colour, Pain, Frequent, Blood, Smell,
Incontinence, Burning, Itching, Dribbling, Have
to get up at night to urinate, Recurrent Urinary
Infections, Rashes or lumps on genitals?
NERVOUS SYSTEM
Concentration, Memory, Vertigo, dizziness,
Fainting, Pain, Loss of Function, Numbness,
Tingling, Gait, Blackouts,
Hearing, Vision problems, Stroke, Brain Injury,
Difficulty Sleeping
MUSCULOSKELETAL
Pain, Stiffness, Numbness, Tingling, ROM,
Trauma, Spasm, Backache, Aching or swollen
joints, Back or neck pain, Painful, blue or white
fingers and toes with cold weather
SKIN
Scalp, dandruff, itching, burning, Dry, Oily,
Allergies, Rashes, Moles, Psoriasis, Dermatitis,
Eczema etc
MALE REPRODUCITVE
Sexual activity, libido, prostate, discharges,
STD’s Contraception Use, Operations,
FEMALE REPRO
Menarche Onset, , Cycle Length, Freq,
Duration/Length of Bleed, Colour, Flow, Clots,
PMT, Mid Cycle events, Pain, Symptoms during,
before, after, OCP, IUD use, Discharge,
Pregnancy, Miscarriages, Infertility, STD’s,
libido, level of activity,
SLEEP
Duration/ how long, Time they go to bed, time
they go to sleep, refreshed or unrefreshed on
waking, Dreams, Wakes time,
What position in mot comfortable for you to
sleep in?
ENERGY
None, some, plenty
Always tired, score /10
THERMALS
Hot, Cold, reactions to environment, what’s too
hot or too cold for you, What weather do
you like and dislike?
CRAVINGS AND AVERSIONS
Foods you crave, eat often
Foods you cannot tolerate
PERSPIRATION
Do you perspire easily, color, smell, where on the body do you sweat
MENTAL / EMOTIONAL
Anxiety,
Stress,
Fear,
Depression Grief, relationships with family,
work, friends, coping mechanisms, reactions to
environment, Stress Management techniques,
Crying, Weeping, Motivation, Will, Drive,
Desires, Goals in life, Habits, Prefer Company,
Alone, or being alone Like Consolation- or not
thoughts you experience and feel, worrying
thought you have and how often
LIKES AND DISLIKES
What do other people like about you?
What do you like about you?
What attributes, attitudes and behaviours do
you like in other people?
What attributes, behaviours and attitudes do
you not like in other people?

What makes you angry/upset?

______

Symptoms that May Be Attributable to Allergies

Please tick  in 

Key Symptoms:

1. Over or underweight or fluctuating weight

2. Persistent fatigue that isn’t helped by rest 

3. Occasional swellings around eyes, hands, abdomen, ankles, etc

4. Palpations or speeded heart rate, particularly after meals

5. Excessive sweating, not related to exercise

HeadHeadache (mild, moderate) 

Migraine

Sick headaches

Solid feeling

Pressure

Throbbing

Stiff Neck

Stabbing

EyesRedness, itching

Blurred vision

‘Sandy’ or gritty feeling

Seeing spots

Heavy eyes

Seeing flashing lights

Dark rings under the eyes

Double vision (comes & goes)

Unnatural ‘sparkle’ to the eyes

Watering

EarsRinging in the ears

Hearing loss

Itching & redness of outer ear

Recurring infections

Earache

Cardio-Rapid or irregular pulse

VascularChest pain

SystemPalpations, esp. after eating

Tight chest 

Pain on exercise (angina)

Raised blood pressure

LungsTightness in chest

Wheezing

Hyperventilation

Coughing

Poor respiratory function

Nose, throatMetallic taste

& MouthPost-nasal drip

Mouth ulcers

Stuffed up nose

Frequent sore throats

Sinusitis

Stiffness of throat or tongue

Sneezing

Gastro-Nausea

IntestinalDiarrhoea

SystemDyspepsia

Constipation

Variability of bowel function

Abdominal bloating

Flatulence

Hunger pangs

Acidity

Pain in stomach

Abdominal stress

SkinEczema

Urticaria (hives)

Rash (no eczema)

Excessive sweating

Itching

Blotches

Chilblains

Musculo-Swollen, painful joints

SkeletalAching muscles

SystemMuscular spasm

Shaking (esp. on waking)

Cramps

Fibrositis

Pseudo-paralysis

Genito-PMT

UrinaryMenstrual difficulties

SystemFrequency of urination

Genital itch

Bedwetting

Urgency

Burning urination

NervousInability to think clearly

SystemMemory loss

‘Dopey’ feeling

Stammering (attacks)

Terrible thoughts on waking

Insomnia

Maths & spelling errors

Blankness

Delusion

Crabby on waking

Hallucination

Difficulty waking up

Desire to injure self

Convulsions

Light-headedness

OtherSudden tiredness after eating

SymptomsSudden chills after eating

Over or underweight

History of fluctuating weight

Vertigo

Abrupt changes: well to unwell

Feeling unwell all over

Feeling totally drained and

exhausted

Persistent fatigue not helped by 

rest

Occasional swelling of face,

hands, ankles

Notes: ______

This list contains symptoms most commonly encountered with allergies and mal-adaption syndrome. It is far from complete.

There should be no other explanation for these symptoms.

Most of the symptoms could be caused by some other illness, although several – such as sneezing attacks – are peculiar to allergies. What really matters is the spread of the symptoms: the more of these someone has, the more likely it is that someone’s illness is allergic in origin

Abrupt changes from being well to unwell (well one minute, sick a few hours later) are also characteristics of allergic reactions.

This list is based on the research of Theron Randolph, Richard Mackamess, Vicky Rippere and Marshall Mandell.

 Mathias Jentzsch, HP

BIORESONANCE – BICOM

Before undergoing Bio-resonance it is important for us to have the following information

1. Do you have a pace maker or any other battery

operated or electrical implant?Yes/No

2. Do you have any metal implants?Yes/No

3. Do you have any metal at all in your body?Yes/No

4. Do you wear hearing aids?Yes/No

5. Are you pregnant?Yes/No

I have read and understood all the above information and questions.

Client’s Signature......

Name...... Date......