Date of Birth

Street Address

Suburb

Postcode

Phone

Email Address

Occupation

Emergency Contact

Name & Phone Number

Current Doctor

Name, Phone & Address

If other, who referred you

Main Presenting Health Concern

When did these symptoms start?

What health goals would you like to achieve

How long do you believe it will take to achieve this

In most cases, depending how long your health issues have been around depends on how long healing may take. Understand patience & work are needed to heal, our bodies are truly amazing.

Current Medications and/or Supplements

Name, Dosage & Frequency

Number of Births

If any other allergies or intolerances, please explain

How many hours sleep do you get on average

How would you rate your stress (10 being high)

Any other health concerns or symptoms you would like to mention

initial client intake form

Copyright Botanic Avenue 2025.