Health Assessment

To best help you with your current problem we first need to find out what symptoms you are experiencing. Please complete this questionnaire at least 24 hours before your initial appointment.

What are your contact details
Name*
Phone*
Date of Birth*
Email
Enter Email Confirm Email
Occupation*
Have you been to a G.P regarding this health problem*
Who is your GP*

Please state GP's name and medical practice
Were you referred to us?
Please let us know who you were referred by
Are you pregnant or planning on getting pregnant in the near future?*
Tell us a bit about your condition
What's your current health status?*
Please provide a bit of detail about your current health and your health complaint(s)
What are your symptoms?*
What symptoms are you experiencing and for how long have you been experiencing them?
Choose 1 main symptom that you would like to address*
Choose a symptom then pick a number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Please describe your symptom
Symptom 1 score*
Choose a number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Choose a 2nd symptom that you would like to address*
Choose a symptom then pick a number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Please describe your symptom
Symptom 2 score*
Choose a number to show how severe your problem has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
Activity affected
Choose one activity - physical, social or mental - that is important to you, and that your problem makes difficult or prevents you doing. Score how bad it has been in the last week.
Please describe your affected activity
Activity score*
Score how bad it has been IN THE LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
General Wellbeing*
How would you rate your general feeling of wellbeing over the LAST WEEK - 0 being as good as it could be and 6 being as bad as it could be
What Medication are you currently taking*
Is cutting down any medication:
Do you feel that stress, diet or lifestyle has played a role in your symptoms?*
This will be discussed in your clinic session but please let us know if you feel one (or more) of the above either has in the past or is currently affecting your condition
Background Information
Family History (if known)
Tell us a little about any relevant family history related to your condition
Medical History
Please tell us about your health background including any chronic illness, allergies, accidents, childhood illness, injury or recent illness
Please tell us about your past antibiotic use*
We would like to know approximately how many times you have used antibiotics in your life and also how recently. Include any side effects you experienced.
What Natural Remedies or Supplements are you taking*
What are your expectations for treatment?*
Please explain
What are your Health Goals*
What are your health goals? Please let us know what you would like us to help you with the most. We will discuss these goals further at your appointment.
Today's Date*
DD slash MM slash YYYY

Thank you for filling out this form, please submit your form and this will be emailed to the team.

Health Assessment

What are your contact details

Tell us a bit about your condition

Background Information

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