• Pre-consultation Health Questionnaire

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  • Health Concerns:

    Please choose one or two symptoms (physical or mental) which bother you the most.

    These will be your main health concerns, which I will support and could be symptoms such as stress, frequent colds, asthma, high blood pressure, shortness of breath, tiredness, thyroid issues, diabetes etc.

  • If you have consulted a therapist, consultant or practitioner for the above symptoms, please provide details below

  • Previous medical history

    For example: Allergies, anxiety or depression, arthritis or rheumatism, asthma or breathing problems, bowel problems, cancer, diabetes, drug or alcohol dependence, ear, eye or throat problems, eczema or skin conditions, epilepsy, heart conditions, hypertentionsin, onfections or diseases (e.g. mumps, measles, chicken pox), kidney conditions, menstrual/mrnopausal conditions, osteoporosis,  sleep problems, stomach ulcers, thyroid problems, tumours, urinary tract conditions.

  • Medications

  • Family medical history

    Please provide details below of family health conditions: e.g. angina, allergies, alzheimer's, arthritis, asthma, blood pressure, cancer, dementia, diabetes, heart disease, lung disease, osteoporosis, parkinson's disease, skin conditions, stroke:

  • Additional information

  • Should be Empty: