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    Thank you for taking the time to fill out this health questionnaire. Please complete and return the form to me at least 48 hours before your appointment to allow me sufficient time to prepare for your visit.

    All information is strictly confidential and will never be shared or disclosed with third parties. Information will not be shared with referral to another medical professional without your prior written consent.

    All history is totally relevant to how your body responds to everyday activities and injuries so please try to fill in as much information as possible. Often incidents which you feel are nothing could in fact be everything - a drunken fall as a teenager, a small scar, a slight ankle sprain.

     You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose. 

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    About your session

    Your session may contain elements of movement as well as massage and release work. With this in mind, please make sure you are wearing clothes that you can move in. 

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • PRESENTING COMPLAINT

  • GENERAL MEDICAL HISTORY

    Do you suffer, or have you suffered from any of the following conditions:

  • MUSCULOSKELETAL ISSUES*
  • CIRCULATORY ISSUES*
  • STRESS REALTED OR PSYCHOLOGICAL ISSUES*
  • RESPIRATORY ISSUES*
  • SKIN ISSUES*
  • DIGESTIVE ISSUES*
  • NEUROLOGICAL ISSUES*
  • EYE ISSUES*
  • JAW & THROAT ISSUES*
  • URINARY ISSUES*
  • HORMONAL ISSUES*
  • IMMUNE SYSTEM ISSUES*
  • MISCELLANEOUS*
  • Are you wearing or do you normally wear:*

  • PAST INJURY HISTORY

  • BREATHING SECTION

  • Please tick any of the symptoms that relate to you:*

  • PREGNANCY AND POST NATAL HEALTH

  • Please tick any of the conditions below, applicable to your pregnancy , birth or post natal period*

  • HYSTERECTOMY SECTION

  • Hysterectomy Surgery type*
  • Surgical Procedure*
  • Reason for Hysterectomy*

  • NEWSLETTER CONTACT CONSENT

  • We would love to send you newsletters and useful info from The Pain and Movement Detective by email. We'll always treat your personal details with the utmost care and will never share, disclose or sell them to any third parties. You can read more about our privacy policy at https://thepainandmovementdetective.com Please let us know if you would like us to contact you or not by selecting one of the options below*

  • I confirm that I have provided details of all known conditions and history. If anything changes, I agree to keep my practitioner updated before any future appointments (Please sign or TYPE YOUR NAME IN CAPITALS BELOW)

  • Date*
     - -
  • Should be Empty: