NEW PATIENT CONSULTATION FORM

NEW PATIENT CONSULTATION FORM

Please fill in the form below. This information will help us paint a picture of your current health situation before we start the Tuning Process.
Name

First Name Last Name
Date of Birth

Month Day Year Date Picker Icon
E-mail
Contact Tel

Address

Street Address
Street Address Line 2
City	Country
Postal / Zip Code	Country

Marital Status

Single Married Divorced Partner
Gender

Male Female
Children? State the Number & their ages
How did you hear about The Tuning Room?
If you were referred by a friend or family member, please tell us who, THEY WILL BE REWARDED!
OCCUPATION
tell us how long you have worked in this field
Sports/Hobbies
Number of times/week
In your own words, please describe your problem (s).
Please tick if you have had any of the following symptoms

Low back pain Mid back pain Neck pain Shoulder pain Elbow pain Hand/wrist pain Hip pain Knee pain Ankle/foot pain Dizziness Tinnitus Vertigo Headaches Ear Infections Asthma Sleep problems Sinus problems Pins & Needles Epilepsy Tumous Heartburn Indigestion Bloating IBS Diabetes ( 1/2) High Blood Press Chronic Fatigue Kidney/Liver Iss CV (heart) Issues Thyroid issues Anxiety Depression Autism Phobias Panic Attacks Palpitations ADHD OCD Mental Health Issues
Please list any medications you are currently taking
Have you ever had any surgeries in your lifetime?

YES NO
If you answered yes, please list your surgeries and include the date (s)
Have you ever suffered any physical trauma in your lifetime? E.g. road traffic accidents, concussions, broken bones, etc

YES NO
If you answered YES, please tell us what happened and include the date (s)
Please list any x-rays or scans you have had in your lifetime
include the dates
If you have the scans you can choose to upload them here
Please give your GP Name & Surgery Address
If required, do you give consent for us contact your GP
Yes/No
Please tick this box to consent to contact in line with the GDPR regulations May 2018. This will allow us to send your appointment reminders via email. You also consent to receiving other relevant chiropractic related information to supplement your treatment.

Yes, I am happy for The Tuning Room to contact me via email No, I do not wish The Tuning Room to contact me via emal
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