Forms

Below is the Personal Health History Form that you need to complete and submit before an Initial Consultation for any treatment.

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Your Name: *

First

Last

Your Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Your E-Mail Address: *

Contact Number: *

Date of Birth: *

Age: *

Height: *

Marital Status: *

Do you have any children? How Many? *

Name of GP and Practice: *

Occupation: *

Have you ever had any Structural Integration, Bodywork, Osteopathy or Chiropractic treatments before? *

• Yes
• No

If you answered yes to the above question, please state What, When and with Whom?

Do you have any chronic aches and pains? *

• Yes
• No

If yes, please specify, where and how long they have been ongoing?

Have you had any fractures or surgeries? *

• Yes
• No

If yes, please state:

Have you had any accidents, car or otherwise? *

• Yes
• No

If yes, please give details:

Have you ever had a head injury? *

• Yes
• No

If you answered yes to a head injury, have you had any complications from this? *

• Yes
• No

If yes, to either question please provide further details:

Have you had any illnesses in the last 12 months and if so what? *

What medication are you taking regularly or have taken over the past 6 months? Please State: *

Do you have or have you ever had any of the following? *

• Aneurysm
• Arthritis – Rheumatoid
• Arthritis – Osteoarthritis
• Asthma
• Back Problems
• Bladder or Bowel Problems
• Cancer
• Connective Tissue Disease
• Diabetes
• Disc Problems
• Epilepsy
• Fibromyalgia
• Haemophillia
• Heart Condition
• High Blood Pressure
• Low Blood Pressure
• Joint Problems
• Migraines/Headaches
• Muscle Cramps or Nerve Problems
• Neck Problems
• Osteoporosis
• Sciatica
• Scoliosis
• Stroke
• Varicose Veins
• All of the Above
• None of the Above

(Please check all that apply)

If yes to any of the above, please provide further details with dates:

For women because of the abdominal work – Do you wear a coil? *

• Yes
• No
• N/A

Are you pregnant? *

• Yes
• No
• N/A

If yes, how many months?

Do you wear contact lenses, a hearing aid, dentures or a bridge? *

• Yes
• No

If yes, please state what:

Do you take regular exercise? *

• Yes
• No

you of injury,

If yes, please state what and how often?

Do you undertake any form of stretching? *

• Yes
• No

Do you feel that flexibility is an important part of fitness?

Do you smoke? *

• Yes
• No

If yes, please state how often and for how long?

Do you drink alcohol? *

• Yes
• No

If yes, how many units a week?

How much water do you drink? *

What is you typical diet like? *

Please list your reasons for seeking treatment and the goals that you wish to achieve during your Bodywork Sessions? *

How and when did your symptoms begin and how long have you had them? *

Are there any other medical conditions that your therapist should be aware of? *

• Yes
• No

If yes, please provide further details:

GDPR Agreement *

• I consent to having this website store my submitted information so they can respond to my inquiry.

Signature: *

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Print your Name: *

Date: *

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