New Patient information
Thank you for completing the form above.
We take our responsibility of holding your personal data very seriously and we are registered with the Information Commissioner’s Office. This ensures that any personal information we hold about you will be given the highest level of protection in accordance with the General Data Protection Regulations 2018.
For further details of how we use your information and how it is protected, please
see our small print.
Please complete the form below providing as much information as possible. If you have any questions then please contact me via email.
Family healthy history
Please give details of the health history of your relatives. For example: Diabetes, heart disease, cancer, tuberculosis, thyroid, glandular fever, rheumatism, mental disease, suicide, alcoholism, etc.
Please write below any/each of the following conditions you have had:
Abscesses, AIDS/HIV, Alcoholism, Anaemia, Arthritis, Asthma, Cancer, Chicken Pox, Colitis, Depression, Diabetes, Eczema, Emphysema, Epilepsy, Gallstones, Goitre, Gonorrhoea, Gout, Hayfever, Heart Disease, Hepatitis, Herpes genetalia, Influenza, Kidney Disease, Leukaemia, Malaria, Miscarriage, Mumps, Parasites, Pleurisy, Pneumonia, Prostatitis, Rheumatic fever, Rubella, Strep Throat, Sinusitis, Stroke, Syphilis, Tonsillitis, Tuberculosis, Typhoid Fever, Venereal Warts, Warts, Worms, Yellow Fever.
In this next section, Please provide as much information as possible including dates. Remember to mention your approximate age at the time of any health problems.
Skin conditions
Please list below
Weather & Environmental reactions
Appetite & Thirst
How much of the following do you consume?
Fears or Phobias
Dreams
Sleep position
send
Any other health problems including life trauma, grief, shocks etc.
