CIT: Centre for Health, Community and Wellbeing.

Naturopathic
Student Clinic 2010.

Naturopathic Student Clinic Consultation

Date:________________________________

Initial / Return

Client File No:_________________________

Age___________________________________________

Sex___________________________________________

Height_________________________________________

Weight_________________________________________

Smoker/non-smoker______________________________

Medications/Drug use_____________________________

Sleep (quantity/quality)___________________________

Exercise________________________________________

Appetite_______________________________________

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

PHYSICAL EXAMINATION

Blood Pressure Pulse Temperature

Skin Hair Nails

Tongue Face Posture

Other__________________________________________________

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Presenting Complaint/s Body Systems Previous Treatment

(In order of priority) Involved

Presenting Complaints

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Gastrointestinal Tract
Mouth (Last dental check, mucosa, gums, teeth, tongue, breath, lips)

Stomach (Pain, HCl level, burning, reflux, heaviness, undigested food, burping,
belching, bloating)

Small Intestine/ Pancreatic function (pain, pancreatic enzyme level,

gas, wind, bloating, distension, undigested food in stool, allergies)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Liver and Gallbladder (pain, tenderness, biliousness, nausea, fat

intolerance, body temperature, night sweats, steatorrhoea, mood, chemical
sensitivities, allergies)

Large Bowel (pain, bacterial environment, gas, wind, bloating, distension,

flatulence, undigested food, tenderness or pain on palpation. Stools, regularity,
diarrhoea, constipation, mucus, blood, shape, colour, smell, haemorrhoids,
fissures)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

NERVOUS SYSTEM (signs and symptoms of overactivity or

underactivity, NS diseases/ conditions, palpitations, energy, sleep, concentration,
memory)

ENDOCRINE FUNCTION

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Adrenal Function (Stress response and adaptation, energy, blood glucose,

NS function, Immune function, thyroid, reproductive)

Thyroid Function (Energy, metabolism, GIT function, NS function,

temperature, reproductive function, goitre, skin, appetite, body weight)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Pancreatic /Blood Glucose/Insulin (Energy, blood glucose regulation,

BGL test? Body weight, functional hypoglycaemia, Hyperglycaemia, insulin
resistance, metabolic syndrome, Diabetes)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

CARDIOVASCULAR
Heart (BP, diseases/conditions, pulse/rate, fitness, emotional wellbeing, CV risk
factors, family history, cholesterol, triglycerides)

Circulation (diseases /conditions, arterial, venous, general, peripheral, micro)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

THE IMMUNE SYSTEM

Infections (viral, bacterial, location?, frequent/recurrent)

Allergies (Atopy, food, environmental)

Lymphatic Function (movement, exercise, hydration, fat intake, fluid

retention, fibrocystic breast disease, cystic acne, swollen lymph glands)

Lifestyle Factors Influencing Immunity

RESPIRATORY SYSTEM (infections, asthma, hayfever, allergies, lung

disease)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Upper Respiratory Lungs

SKIN (diseases, temperature, pallor, circulation, hydration, EFA status, sun

exposure, hormone balance)

RENAL SYSTEM / KIDNEYS (oedema, infections, kidney function,

hydration, urine output/concentration, kidney stones, cystitis, BPH)

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Male Reproductive (BPH, Prostate cancer, frequency, hesitancy, urgency,

sexual health screening, sexual function)

FEMALE REPRODUCTIVE
Menstrual Cycle
Length Ovulation Luteal Bleeding
Phase Phase

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Fertility (History/Current)
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Infections________________________________________
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Last Pap Smear/Breast Check_________________________
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Conditions________________________________________
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Musculoskeletal
Muscles (tension, injury, muscle mass, chronic conditions )

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Skeleton (bone density, injury, conditions, spinal health, sun

exposure/vitamin D and calcium intake)

DIETARY INTAKE
Breakfast Lunch Dinner

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Snacks/Treats Alcohol/other Water

beverages

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CIT: Centre for Health, Community and Wellbeing. Naturopathic
Student Clinic 2010.

Possible Dietary Deficiencies

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OTHER NOTES

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