Patient Intake Form

Please complete this form before your initial consultation. Your detailed answers help Dr. Wayne identify the root cause of your concerns.

Form Progress

Clinical Grade

1. Personal Information

Your basic contact and demographic details.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

How did you hear about us?

2. Primary Health Concerns

What brings you to the clinic today?

What is your most important health concern? *

How is this affecting your daily life?

Mildly - I can mostly function normally

Moderately - It interferes with some activities

Severely - It significantly impacts my daily life

3. Medical & Family History

Past health events and family patterns.

Significant Family Health Conditions

Past Surgeries or Major Illnesses

4. Medications & Allergies

Current chemical and natural interventions.

Current Prescription Medications

Current Supplements & Vitamins

Known Allergies & Sensitivities

5. System Review & Hormones

Specific symptoms across your body systems.

Digestive System

Hormonal Concerns

Energy Levels (1-10)

Stress Levels (1-10)

6. Lifestyle & Goals

Your habits and what you want to achieve.

Top 3 Health Goals *

Typical Daily Diet

Sleep Patterns

7. Terms & Privacy Consent

By submitting this form, you acknowledge and agree to the following:

The information provided is accurate and complete to the best of your knowledge.
This data will be used by Dr. Wayne Pickstone for clinical assessment and treatment planning.
Your privacy is paramount. All information is handled in accordance with Australian Privacy Principles.
Naturopathic care is complementary and does not replace emergency medical treatment.
We require at least 24 hours notice for cancellations to avoid a cancellation fee.

I have read and agree to the clinical terms, privacy policy, and cancellation policy. I consent to Dr. Wayne Pickstone reviewing my health information. *

Electronic Signature (Type Full Name) *

Digital Signature

By typing your name above, you are providing an electronic signature that is as legally binding as a handwritten signature.