A S Therapy Medical Form
Please complete the online form to the best of your knowledge. The online medical form is for our records only allowing us to provide the best service and treatment possible. Before filling out the online form please read the Consultation T&Cs and Cancellation Policy which can be found at www.astherapy.co.uk under INFORMATION.
Mr / Mrs / Miss / Ms
Select an option
-
Mr
Mrs
Miss
Ms
First Name
Last Name
Date of Birth dd/mm/yyyy
10
Email
Address
Contact Number
Occupation
70
Are you currently receiving care by another health care professional?
No
Doctor / GP / Nurse
Physiotherapist
Chiropractor
Osteopath
Masseuse
Dietitian
Dermatologist
Councillor / Therapist
Are you on any medication for any conditions or illnesses you may have?
Yes
No
Have you had any major / minor operations or surgeries?
Yes
No
If you have answered 'Yes' to the above question please give details?
Have you ever had a serious head and/or neck injury?
Yes
No
If you have answered 'Yes' to the above question please give details?
Do you have or know of any bladder or bowel disease or disfunctions?
Yes
No
Not Sure
Do you exercise regularly?
None
1 - 2 times per week
3 - 4 times per week
5+ times per week
How many hours do you sleep?
Less than 3
3 - 5
6 - 8
8+
Do you follow a restricted diet?
Yes
No
Do you consume alcohol?
No
Rarely
1 time per week
2 - 3 times per week
Everyday
Do you smoke?
No
Rarely
Less than 5 per day
6 - 10 per day
Over 10 per day
Have you any allergies?
Yes
No
If you have answered 'Yes' to the above question please give details?
Are you or could you be pregnant?
N/A
Yes
No
Maybe
How would you rate your current stress level? 1.Low / 5.High
Select an option
0
1
2
3
4
5
Are you currently suffering from any mental health conditions?
Yes
No
Rather not say
Do you have or have had any of the following?
Anxiety / Depression
Arthritis / Gout
Artificial Joint
Asthma
Blood Clots / Clotting
Bruise Easily
Cancer
Chest Pains
Circulatory Problems
Convulsions
Deep Vein Thrombosis
Diabetes
Epilepsy / Seizures
Fainting / Dizziness
Fatigue
Frequent Headaches / Migraines
Hearing problems
Heart Attacks / Disease / Failure
Haemophilia
Hernia
High Blood Pressure
Infectious Disease
Kidney Problems
Low Blood Pressure
Osteoporosis
Respiratory Problems
Skin Conditions
Sleep Difficulties
Stroke
Varicose Veins
None
If there are any other illnesses or conditions not listed and you wish to disclose please write in the box below:
Please give details* - How did your injury/injuries happen?
Please give details* - Where is the pain located?
Please give details* - On a scale of 1 to 10 how much pain are you in? **10 being the highest
Select an option
0
1
2
3
4
5
6
7
8
9
10
Please give details* - How long ago did it happen?
Please give details* - What makes it better?
Please give details* - What makes it worse?
What would you like to get out of your treatment?
Is there anything else you wish to disclose?
Emergency Contact First and Last name
Emergency Contact Phone Number
I have read a copy of the Consultation T&Cs and Cancellation Policy. I agree to proceed with the treatment & future treatments carried out by the therapist.
Signature
*
Clear
Submit
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