Consultation Form

1

To start, I need your full name* This field is required.

First Name

Last Name

2

What is your date of birth?* This field is required.

3

Please write down your email address* This field is required.

example@example.com

4

What is your phone number?* This field is required.

5

Please select if you have any of the following problems or conditions* This field is required.Select one or more conditions that you have

BLOOD CIRCULATION, HEART and/or BLOOD VESSELS (arteries, veins)

PREGNANCY • Less than 3 months pregnancy.

EATING, DRINKING, DIGESTING and EXCRETING • Problems or conditions affecting your mouth, gullet, stomach, intestine or bowels. • Problems with your kidneys, bladder or liver.

BODY REGULATION & SKIN • Hormone – related problems or conditions (e.g. diabetes, over- or under- active thyroid) • Suffering from difficulty in maintaining body temperature, disorders of or problems with the skin, hair, or nails, or excessive sweating.

IMMUNE & LYMPHATIC SYSTEM • Allergies or sensitivities • Currently suffering from, or recovering from an infection of any type • Problems with your immune response • Oedema.

MOVEMENT, MUSCLES, JOINTS & BONES • Problems or conditions which make it hard for you to move your legs or arms, fingers and toes or joints • Fractured bones in the last 12 months • Not able to lie still for periods of up to 30 minutes.

PAIN, NERVOUS SYSTEM & BRAIN • Suffering from chronic (on going) pain in any part of the body • Experiencing pain at the current time • Suffering from anxiety, depression, confusion or other mental states.

BREATHING • Breathing difficulties or lung conditions • Become breathless on exertion • Unable to climb a flight of stairs without difficulty.

I DON'T HAVE ANY PROBLEMS OR CONDITIONS

OTHER

6

Please give details of any treatment you are receiving for the selected conditions

7

Are you currently receiving any treatment from any health professional, for example doctors, nurses, physiotherapists, pharmacists, etc. (including but not restricted to medications, therapies, surgery, ongoing monitoring, outpatient appointments) which you have not mentioned above?If so, please give details

8

Please, sign here* This field is required.

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