Welcome to Valtality. Before we can get started we need to take a full client history. Please take 15-20 minutes to fill out this form and sign and submit when you’re done.
Thank you.
Have you seen a Naturopath before?
Have you used Liquid Herbal Extracts before?
Other medical treatment received
Please indicate if you have a personal or family history of any of Heart Condition
Please indicate if you have a personal or family history of any of Low Blood Pressure
Please indicate if you have a personal or family history of any of High Blood Pressure
Please indicate if you have a personal or family history of any of Diabetes
Please indicate if you have a personal or family history of any of Neurological Condition
Please indicate if you have a personal or family history of any of Spinal or Head Injury
Please indicate if you have a personal or family history of any of Respiratory Issues
Please indicate if you have a personal or family history of any of Kidney Disorder
Please indicate if you have a personal or family history of any of Cancer
Please indicate if you have a personal or family history of any of Hepatitis
Please indicate if you have a personal or family history of any of HIV/AIDS
Please indicate if you have a personal or family history of any of Osteoporosis
Please indicate if you have a personal or family history of any of Headaches/Migraines
Please indicate if you have a personal or family history of any of Sprains/strains/fractures
Please indicate if you have a personal or family history of any of Arthritis
Please indicate if you have a personal or family history of any of Jaw Pain
Please indicate if you have a personal or family history of any of Dizziness/Fainting
Please indicate if you have a personal or family history of any of Contagious Illness
Please indicate if you have a personal or family history of any of Skin Conditions
Please indicate if you have a personal or family history of any of Digestive Conditions
Please indicate if you have a personal or family history of any of Lung Conditions
Please indicate if you have a personal or family history of any Reproductive (menstrual/fertility/libido) issues?
Please indicate if you have a personal or family history of any Mental health issues?
Please indicate if you have a personal or family history of Wearing a Pacemaker
Please indicate if you have any Upcoming Surgery
Please add any recent test results if applicable
It's important for us to collect your personal information before any consultation with you, so we can provide the best service at our practice.
Your personal information will be held confidentially in electronic record and in a manner that reasonably protects it from misuse and loss and from unauthorised access, modification or disclosure. Personal information will only be used for medical services and for payments, otherwise we will consult you for your consent.
Your personal information will not be disclosed with any third party without full disclosure with you. We will explain the reason beforehand, and will only share it with your consent.
There are some exceptions to disclose without your consent and that includes where we are required or authorised by law; this may include to prevent a serious threat to a patient's life or safety or to someone else's life, or if we are unable or it is impractical to obtain the patient's consent.
We will not use your personal information in any direct marketing without your consent. Appointment confirmations are not considered marketing communications.
*Do you accept this policy?
