Holisticare New Patient Form

Consent:

By submitting this form, I consent to my details being added to the Holisticare database. For patients receiving video or phone consultation: I understand that any advice given remotely is based on the information that I provide, and is limited as no physical examination has been carried out. I understand that this advice does not replace medical attention and that I am responsible for seeking medical help if required.
Holisticare New Patient Information

Thank you for completing this form.
Gender*
Title*
Name*

First NameLast Name
Preferred name, if different from above
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

Village/town/cityCounty

Postcode
E-Mail*
example@example.com
Is it ok for us to email you occasionally with information and offers? We will never share your details with any third party.*

YesNo
Home Phone Number
Mobile Phone Number*
Occupation*
Name of emergency contact*
Relationship*
Contact number*
Please tell us how you heard about us, with the referrer name if applicable*
GP surgery and name*
Medical History
History of current condition - Please include how and when your condition started, any medical or complementary treatment received.*
What is your goal of treatment?*
Please list your Current Medications*
Please tick all of the options that apply to you*

AsthmaDiabetesEpilepsy SeizuresFainting SpellsPregnantHeart DiseaseHigh Blood PressureLow blood pressureDigestive ProblemsBladder problemsSleep ApneaBleeding DisordersLung DiseasePace makerDefibrillatorHeadachesUnexplained weight lossNone
Are you allergic to anything?*
Do you have any pins and needles or numbness? Please give details.*
Past Medical History: For the whole of your life - please include any operations, hospital admissions and treatments, breaks, sprains, physical or mental traumas, bereavements, accidents, falls, childbirth etc. Please include rough dates, left/right side of your body, etc.*
Any other relevant information?
eg. Caring responsibilities, day to day stresses
Lifestyle
Do you do any regular exercise? Please give details*
Do you have any problems sleeping?*
Diet - details of any restrictions, balance, healthy?*
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
How would you describe your stress levels?*
How do you relax?*
Should be Empty:

Holisticare New Patient Information

Medical History

Lifestyle