Your name
Your email
Presenting Conditions and medical diagnosis (if any)
How does this affect your day to day activities/hobbies
What aggravates your symptoms and what gives you relief
How does this condition affect you generally (sleeping pattern/anxiety/stress levels etc…
Clients expectation of treatment:-
Acupuncture; Auricular Acupuncture; Bowen Therapy; Bowen Lymph work; MSTR Scar work; B12 injection. A
Medical Checklist
1: Have you had the recent onset of a new continuous cough? ---YesNo
2: Do you have a high temperature? ---YesNo
3: Have you noticed any loss or change in your normal sense of taste or sense of smell ---YesNo
4: Have you noticed a new rash on your arms or legs ---YesNo
5: Have you been abroad in the last 14 days? ---YesNo
6: Does anyone in your household have symptoms of Corona virus? ---YesNo
7: Have you tested positive for COVID 19 in the last 7 days? ---YesNo
8: Have you had the COVID 19 vaccine? ---YesNo
Current Medication
List and date previous operations
Epilepsy---YesNo
Heart Disease/BP---YesNo
Currently Pregnant---YesNo
Fractures ---YesNo
Digestive ---YesNo
Respiratory ---YesNo
Genito/Urinary ---YesNo
Circulatory ---YesNo
Allergies ---YesNo
Whiplash Injury ---YesNo
Other Health Issues