Book your appointment

You can now book your appointment online through our website.
Please complete the form below and we will contact you shortly to confirm your appointment.
Surname :
Forenames :
Title :
Date of Birth
Gender
Full Address :
Postal Code :
Nacionality :
Telephone :
Email Address :
STRESS
From a scale of 1 to 10, how would you rate your stress level?
Not stressed at all
Very stressed
 
ENERGY
From a scale of 1 to 10, how would you rate your energy level?
Not energetic at all
Very energetic
 
WEIGHT
What is your weight now?
What was your weight 10 years ago?
Do you think that you are at your natural weight? YES NOT
Would you like to lose weight? YES NOT
Would you like to gain weight? YES NOT
Is your weight:
Are you on a special diet? YES NOT
If yes, give brief details
 
EXERCISE
How often do you exercise e.g. go to the gym, play tennis, play team sports, swim etc
(Tick appropriate one)
What type of exercise do you undertake?
How long is each session of exercise?
Do you take sufficient exercise to get out of breath? YES NOT
 
SMOKING
Have you ever smoked cigarettes? YES NOT
Do you smoke cigarettes? YES NOT
If yes, how many do you smoke per day?
 
Have you ever smoked cigars? YES NOT
Do you smoke cigars? YES NOT
If yes, how many do you smoke per day?
 
Do you inhale the smoke?
 
ALCOHOL
Are you teetotal? YES NOT
If YES, for how long
If NO, how many units do you drink per week? (1 unit= half and pint of beer OR 1 glass of wine)
 
DIET
From a scale of 1 to 10, how would you rate your diet?
Very poor malnourished diet
Very healthy nourishing diet
 
WORK HAZARDS
Are there any health hazards that you are exposed to at work such as toxic chemicals, dust or fumes?
 
ALLERGIES
If you have any allergies, please note them below:
 
FAMILY HISTORY
Father: (ALIVE, IF YES, AGE, STATE OF HEALTH either poor or healthy)
(DEAD, IF YES, AGE OF DEATH, CAUSE OF DEATH)
Mother: (ALIVE, IF YES, AGE, STATE OF HEALTH either poor or healthy)
(DEAD, IF YES, AGE OF DEATH, CAUSE OF DEATH)
Brothers: (NUMBER, ANY HEALTH PROBLEMS)
Sisters: (NUMBER, ANY HEALTH PROBLEMS)
 
Have any blood relatives had (mark as appropriate):
Are any other health and/or genetic problems in the family?
 
LAST QUESTION
Is there any area of your health not covered above which causes concern? If there is, please detail below.