Name:              Date of Birth:  

Email:               Retype Email:

Gender: ---Select One--- Male Female

Telephone Contacts:

   Office:                    Mobile:

Date of Appointment:                       Preferred Time: ------Select One------ 8.00am 8.30am 9.00am 9.30am 10.00am 10.30am 11.00am 11.30am 12.00pm 12.30pm 1.00pm 1.30pm 2.00pm 2.30pm 3.00am 3.30pm 4.00pm 4.30pm

PATIENT ASSESSMENT QUESTIONNAIRE

To help us plan your treatment, please answer the following questions. Do you suffer from, or have suffered from the following:

Heart disease or heart murmur?   ---Select One--- Yes No        High blood pressure?  ---Select One--- Yes No
Stroke?                                    ---Select One--- Yes No        Kidney problems?       ---Select One--- Yes No
Asthma?                                     ---Select One--- Yes No        Liver problems?         ---Select One--- Yes No
Diabetes (Blood Sugar)?            ---Select One--- Yes No        Epilepsy or fits?          ---Select One--- Yes No

Heartburn or Gastric ulcers?        ---Select One--- Yes No

Haemophilia, or blood clotting problems?  ---Select One--- Yes No
Any allergies, to medicines, strapping, metals, rubber, food, etc?  ---Select One--- Yes No
Any other disease?  ---Select One--- Yes No

If you answered Yes to any of the questions please tell us about it:

Are you taking any tablets, pills, inhalers or medicine? ---Select One--- Yes No
If yes, please list them.

Any other information?