Please complete in full
Please provide as much detail as you are comfortable with, as this form will go directly to your practitioner of choice
The information on this first page goes to our Administration Department
The information you enter from this point on is only seen by your practitioner
TICK ALL THAT APPLY
- STEP 1
- YOU & FAMILY
Full address inc. Postcode
DATE OF BIRTH
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?
YEARS IN CURRENT JOB
PREVIOUS OCCUPATION IF LESS THAN 2 YEARS
HEALTH DETAILS (PLEASE COMPLETE IN FULL)
NAME OF GP
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?
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)
DIABETES (TYPE I OR II)
HEART DISEASE / HIGH CHOLESTEROL
ASTHMA / COPD
MIGRAINES / HEADACHES
HYPERTENSION / HIGH BLOOD PRESSURE
DIGESTION / ULCERS
IBD / CROHN'S / COLITIS
BLADDER / UTI'S
OBESITY / ANOREXIA
DEPRESSION AND/OR ANXIETY
ANY OTHER PROBLEM
ARE YOU CURRENTLY PREGNANT?
CHILDHOOD - before the age of 18, did you experience any of the following
Did you witness abuse
Substance abuse (inc. alcohol)
Poverty/unemployment in the family
Death of a parent
Lack of affection
Serious illness (either you or someone close)
Criminal behaviour (you or family member)
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?
Treatment declaration This form applies to all forms of treatment administered by Life Right - all referred to under the general heading of 'treatment'. Prior to formal commencement of treatment, I, the client understand: Treatment will require my active participation and commitment to achieve the best outcomes It will be beneficial for me to work on goals & objectives as recommended by my practitioner(s) The importance of me being honest and providing accurate feedback to help continue my treatment plan Whilst the practitioner(s) will always try and provide an indication of treatment plan duration, this cannot be definitive until all issues have been presented or identified It is sometimes necessary & beneficial to see more than one practitioner If my presenting issues have been apparent for more than 3 months, they may change or appear to become worse before an improvement is noticed Sometimes the presenting issue is not the cause of what is happening It is my responsibility to disclose all relevant information and to be responsible for withholding, whether intentionally or otherwise Based on the information I provide, I may be offered nutritional supplements to help with my overall wellbeing. I agree to read the label and advise my GP. I also accept full responsibility for any supplements, including the agreed dosage. With my approval, my records may be passed to other practitioners to keep them updated of my progress Life Right at times may contact me via email, text or social media with details of services etc. I can opt out any time I will be charged the full session fee from 08:00 the previous day for online appointments and two days in advance for clinic-based appointments. I will also be charged if I do not attend, or cancel within the times previously stated. I consent for provided payment details to be used. In the event of failed payments, I agree to clear any outstanding debt before I can book further appointments, or order tests/supplements or other items
please type your name to confirm you have completed this form fully and not omitted any information
When you click SUBMIT, you will be taken to the payment authorisation page, where you will need to enter your payment card details