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MrMrsMsMissDrMasterProfessorMx
First Name
Last Name
Preferred Name - If different from above
Date of Birth
Your email
Are you currently taking any medication? If yes please provide details.
Is there a chance you could be pregnant? If yes please provide details.
Do you have any family history of serious illness or diseases? If yes please provide details.
Do you exercise regularly? If yes please provide details.
AsthmaHeart conditionHigh blood pressureDiabetesAnxietyStressEyesight problemsJoint or muscle injuriesBack or neck painConcussion or head injuryRecent surgery or fractureAllergiesNone of the above
Do you drink alcohol? If so how many units per week? (Pint - 2.5 = Units, Wine = 2 Units, Single Spirit = 1 Unit)
Do you smoke cigarettes? If so how many per day?
Do you drink coffee or tea? If so how many cups per day?
What type of pain is it?
How long have you had this condition?
Can you rate your level of pain? 1=least painful - 10 most painful
Have you suffered from any unexplained weight changes? If yes please provide details
Have you ever had any car accidents? If yes please provide details
Have you ever had any serious falls or broken bones? If yes please provide details
Have you ever had any serious sports injuries? If yes please provide details
Please enter the name of your GP Surgery > Doctor's name
Do you have private heathcare (BUPA, AXA, PPP, Simply Health etc)?
Do you have any children? If so how many?
What services are you visiting the clinic for?
What are you experiencing symptoms of your presenting complaint?
Your message (optional)
I confirm that all the information I have provided on this form is correct and complete to the best of my knowledge.
Signed:
Printed Name:
Date:
07760 403996
info@hbperformancerehab.co.uk
