DATE: NAME: DOB: ALLERGIES: Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counseling | Herbal Medicine Mobile: 0431 221 253 | [email protected] | Fax: 02 6678 0424 Initial Consultation Health Details PATIENT DETAILS DATE OF FIRST VISIT SURNAME FIRST NAME DOB SEX CURRENT AGE WEIGHT HEIGHT REFERRED BY PRIVATE HEALTH INSURANCE PROVIDER ADDRESS PHONE (H) PHONE (M) EMAIL OCCUPATION PREVIOUS OCCUPATION MARITAL STATUS CHILDREN: YES/NO (IF YES, LIST AGES) LIST YOUR HEALTH PROFESSIONALS INCLUDING YOUR DOCTOR NAME PHONE PROFESSION NAME PHONE PROFESSION
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Initial Consultation Health Details · DATE: NAME: DOB: ALLERGIES: Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counselling
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DATE: NAME: DOB: ALLERGIES:
Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counseling | Herbal Medicine
Please give a brief description of the history of your health including any diagnosis, conditions, injuries, operations, major events or traumas starting from most current going back to childhood:
AGE HEALTH ISSUE/LIFE EVENT
DATE: NAME: DOB: ALLERGIES:
Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counselling | Herbal Medicine
ConsentI hereby agree and understand that the treatment/advice given will include one or more of the following; dietary prescription, lifestyle prescription, nutritional/herbal/Homeopathic supplements, screening tests, physical examination and massage, which I knowingly and willingly consent to undergo of my own free will. At any time, I may withdraw my consent or reject any treatment or advice without prejudice from the practitioner.I understand that nutritional/herbal supplements are prescribed in a therapeutic fashion and if circumstances change (e.g. pregnancy, cessation/commencement of pharmaceutical drugs, etc.) from what was presented to the practitioner, I will notify the practitioner immediately, so treatment/advice can alter accordingly if required.
Privacy Policy:I consent to the gathering of my health information for the purpose of naturopathic care, case analysis and treatment. I understand that my health information is kept confidential, held in a secure way and for my practitioner’s access only. If there is to be sharing of information for the purpose of mentoring or professional supervision I authorise my practitioner to disclose anonymous information (i.e. no name, date of birth, contact information will be shared) related to my care and treatment to other practitioners for the purposes of clinical supervision and for the benefit of my care and treatment. A third party may lawfully request information if there is a risk of harm to others or myself. I have a right to access my files or have them forwarded to an accredited practitioner via written request. If access to health data poses a serious threat to a person’s health or life, it will be denied. I will provide my practitioner with up-to-date, complete and accurate health information for the purpose of complete naturopathic care. My practitioner will ensure these records are kept current. If I feel there are issues with privacy of my information I will first discuss with my practitioner and I have the right to make a complaint to the Information Commissioner.
Mental Health Consent:If you are consulting Therese regarding a mental health issue Therese will get in contact with your prescribing physician and other relevant medical professionals from the outset so that your care and management can be transparent and coordinated. If at any time Therese is concerned that you are a risk to yourself or to others, she will contact these relevant practitioners and if deemed necessary break confidence and contact your emergency contact person (family member or friend) as listed on the front of this form as well.
By signing this you acknowledge these to be conditions of being a patient of Therese Latta.
DATE: NAME: DOB: ALLERGIES:
Therese Latta - Specialising in Nutrition Naturopathy & Nutritional Medicine (CMA1486) | Dietary & Lifestyle Counseling | Herbal Medicine
I understand that Therese Latta Living Health Natural Medicine is not staffed 24 hours a day. In cases of emergency when immediate help and counsel is needed I understand the local resources available are Emergency Services (dial 000) and Lifeline 13 14 11.