New Client Form

Please complete in full

TICK ALL THAT APPLY

  • STEP 1
  • EMPLOYMENT
  • YOU & FAMILY
  • PAIN

STEP 1

FULL NAME

Mobile number

email address

Full address inc. Postcode

DATE OF BIRTH

MARITAL STATUS

GENDER

NUMBER & AGES OF CHILDREN

HOW DID YOU HEAR ABOUT LIFE RIGHT (IF FROM A PERSON, PLEASE GIVE THEIR NAME)

Have you had both of your covid-19 vaccinations?

EMPLOYMENT

OCCUPATION

EMPLOYER

YEARS IN CURRENT JOB

PREVIOUS OCCUPATION IF LESS THAN 2 YEARS

HEALTH DETAILS (PLEASE COMPLETE IN FULL)

NAME OF GP

GP PRACTICE

CONTACT NUMBER

DOES YOUR GP KNOW YOU ARE ATTENDING LIFE RIGHT?

Are you currently seeing a specialist, other than your GP?

If 'YES', what is their specialism and what are you seeing them for?

WHAT MEDICATION ARE YOU CURRENTLY TAKING?

WHAT MEDICATION WERE YOU TAKING BEFORE BUT ARE NO LONGER?

BROKEN BONES IN THE PAST

ANY PREVIOUS ROAD TRAFFIC ACCIDENTS? (INC. DATES)

PLEASE LIST ANY OPERATIONS OR HOSPITALISATIONS IN LAST 10 YEARS (INC. DURATION)

ANY PREVIOUS X-RAYS

PLEASE DETAIL FROM CHILDHOOD TO PRESENT DATE ANY EVENTS, SITUATIONS, PEOPLE OR TRAUMA YOU FEEL MAY BE SIGNIFICANT IN HOW YOU ARE FEELING TODAY (WITH DATES IN A TIMELINE LIST) (inc. hospital visits or long periods of antibiotics)

THE NEXT SECTION IS FOR WOMEN ONLY. PLEASE GO TO NEXT SECTION IF THIS DOES NOT APPLY

LAST CERVICAL SMEAR

LAST BREAST EXAMINATION

DO YOU CHECK YOUR BREASTS REGULARLY?

LAST MENSTRUATION PERIOD STARTED

PERSONAL INFO (CONTD)

DO YOU SMOKE

IF 'YES', HOW MANY PER DAY?

FOR HOW MANY YEARS?

DO YOU EXERCISE?

TYPE OF EXERCISE?

FREQUENCY

YOUR HEIGHT IN CMS

YOUR WEIGHT IN KGS

HAVE YOU OR A FAMILY MEMBER SUFFERED WITH ANY OF THE FOLLOWING CONDITIONS

PLEASE TICK ALL THAT APPLY

ANY TYPE OF CANCER

CHRONIC PAIN (LONGER THAN 3 MONTHS)

NEURODEGENERATIVE DISORDERS

DIABETES (TYPE I OR II)

EPILEPSY

ARTHRITIS

ADDICTION

ENDOCRINE IRREGULARITIES

HEART DISEASE / HIGH CHOLESTEROL

ASTHMA / COPD

MIGRAINES / HEADACHES

HYPERTENSION / HIGH BLOOD PRESSURE

LIVER

DIGESTION / ULCERS

IBD / CROHN'S / COLITIS

BLADDER / UTI'S

OBESITY / ANOREXIA

SKIN COMPLAINTS

DEPRESSION AND/OR ANXIETY

PSYCHIATRIC DISORDERS

ANY OTHER PROBLEM

ARE YOU CURRENTLY PREGNANT?

What you are experiencing now

ARE YOU CURRENTLY EXPERIENCING ACHES OR PAINS? PLEASE DESCRIBE IN AS MUCH DETAIL AS POSSIBLE

Please describe in as much detail as possible, what we can help you with?

Confirmation

please type your name to confirm you have completed this form fully and not omitted any information

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