Appointment Booking Form

Full Names

Gender

Male
Female

Date of Birth

Date of Birth :: format dd/mm/yy

Occupation

Address

Telephone/Mobile

Telephone/Mobile :: Enter phone number to enable us to confirm to you of your appointment details.

Email.

Select the date you would like to book for an appointment. Weekdays between 9:00am and 4:00 pm. Saturdays 9:00am and 12:00 pm. Sundays and Public holidays closed.

Date

Date :: Select from the calendar

Time

Time :: Choose the time. Weekdays between 9:00am and 4:00 pm. Saturdays 9:00am and 12:00 pm. Sundays and Public holidays closed.

PATIENT ASSESSMENT QUESTIONNNAIRE

To help us plan your treatment, please answer the following questions.

Do you suffer or have suffered from:

A heart disease or heart murmur?

Yes
No

High blood pressure?

Yes
No

Stroke?

Yes
No

Diabetes

Yes
No

Asthma?

Yes
No

Epilepsy or Fits?

Yes
No

Kidney problems?

Yes
No

Liver problems?

Yes
No

Hemopholia or blood clotting problems?

Yes
No

Heart burn or Gastric ulcers

Yes
No

Any allergies? To medicines? strapping, metals, rubber, food, e.t.c

Yes
No

Any other disease?

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?

Yes
No

Any other information?