Background health Childhood (0–18 years) health — accidents, hospital visits, surgery or allergies
Do you have a personal or family history of asthma, eczema, hay fever, glandular fever, rheumatic fever, thyroid conditions, high cholesterol, diabetes, hepatitis, anaemia, IBS, Crohn's, ulcerative colitis, Coeliac, parasite/H.pylori infection, HIV, Alzheimer's, osteoporosis/osteopenia, mental illness, or addictions? Please select Yes No Not Sure
Any diagnosed medical conditions or additional information that may help us support you better?
Occupation and lifestyle Current and previous occupations, and how long in each role
Hobbies or interests you enjoy regularly
Do you have a spiritual practice? Please select Yes No Not sure
Close relationships with family or friends? Please select Yes No It's Complicated
Describe your current home situation (living alone, with family, flatmates, assisted housing; quiet, peaceful, noisy, stressful)
Do you feel safe at home? Please select Yes No
Diet % of foods that are organic Please select 0% 25% 50% 100%
Number of meals a day Please select Less than 3 a day 3 a day More than 3 a day
Do you feel physically hungry? Please select Yes No Not Sure
Do you snack? Please select Yes No Not Sure
What does a typical meal look like for you?
I get hangry if I skip or delay a meal Please select Yes No Not Sure
I crave and regularly eat carbohydrates Please select Yes No Not Sure
I often feel tired after a meal Please select Yes No Not Sure
I drink alcohol Please select Yes No
Additional comments about your diet
Digestive and urinary systems Any major changes in sight, smell, taste or hearing in the last 6 months? Sensitive to perfume or diesel fumes?
Systems review Sleep On average, how many hours of sleep do you get per night?
Difficulties falling asleep (sleep onset)? Please select No Occasionally Frequently
Trouble staying asleep (sleep maintenance)? Please select No Occasionally Frequently
Do you usually wake feeling refreshed? Please select Yes No Sometimes
Vivid dreams or nightmares? Please select No Occasionally Frequently
Do you take naps during the day? Please select Yes No
Do you follow any sleep hygiene practices? Please select Yes No What is sleep hygiene?
Female reproductive health (skip if not applicable) Are you currently menopausal or postmenopausal (no period for 12+ months)? Please select Yes – may skip menstrual cycle questions below No – please complete the questions below
Typical cycle length (regular — every ? days, or irregular — varies between ? and ? days, or no current periods)
Additional comments
Cancer history and prevention (complete only if relevant to you) Family history of cancer? Please select Yes No Not Sure
Chemotherapy or radiation in the past year or at any point? Please select Yes No Not Sure
If diagnosed with cancer — type, stage, date of diagnosis, and any other pertinent information
Major stress or life disruptions around two years before diagnosis? Please select Yes No Not Sure
Abnormal test for a DNA repair mutation (BRCA1, BRCA2, MLH1, TP53, PI3KCA, MTHFR)? Please select Yes No Not Sure
Please email any recent scan reports, blood test results, or genetic/histopathology reports to us directly, or bring them to your clinic consult.
Consent, Privacy & Agreement Clinical disclaimer This intake form collects information to support safe, personalized naturopathic and herbal medicine care. Recommendations provided are supportive and do not diagnose, treat, or replace medical care from your primary healthcare provider. Please disclose all medications, supplements, allergies, pregnancy or breastfeeding status, and significant health conditions before treatment. By consenting you agree to keep your practitioner and medical doctor informed of any changes to your health.
Privacy summary We collect and store your personal and health information only for providing professional care and administrative services. Your data is kept confidential, accessed only by authorized staff, and retained in accordance with our clinic policy and PDPA Singapore. By submitting this form you consent to the collection, use and storage of your personal data for assessment, treatment, billing and follow-up.
Cancellation and refund policy Appointments cancelled less than 24 hours before the scheduled time may incur a cancellation fee. Refunds for prepaid consultations or remedies are processed per clinic policy and may be subject to an administration fee. Please contact the clinic to discuss exceptions or urgent changes.
