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Medical Appointment Booking
Full Name *
Email address *
Contact Number *
Address
Date of Birth *
Height *
Weight *
Medical information
What is affecting you at the moment?
When did it first start?
Have you seen a G.P. or another healthcare professional?
 Yes   No 
Have you had an x-ray or MRI (if so please state results)?
Which parts of your body are affected/in discomfort:
Is this affecting your sleep?
 Yes   No 
Do you experience a sharp pain, dull ache, shooting pains, pins and needles, or blackouts:
What score would you give your symptoms at it's worst out of 10?
What gives you relief from your symptoms, and what score would you give yourself out of 10 at best?
Do you have any thyroid problems?
 Yes   No 
Do you have any heart or blood pressure problems, or a pacemaker?
 Yes   No 
Do you have arthritic changes?
 Yes   No 
Do you have rheumatoid arthritis?
 Yes   No 
Do you have epilepsy?
 Yes   No 
Do you have any respiratory problems such as asthma?
 Yes   No 
Do you have diabetes?
 Yes   No 
Are you currently on steroids, or have history of steroidal medication?
 Yes   No 
Have you had any recent surgery?
 Yes   No 
Please list any medications that you are on:
Is there any other information you that you think is relevant?
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