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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Health History

Heart Condition

High / Low Blood Pressure 

Stroke or Aneurysm 

Pace Maker 

Varicose Veins 

Bruise easily 

other Circulatory condition 


Kidney Disease 

other Urinary condition 

Headaches / Migraines 

Dizziness / Fainting 


Spinal Injury 

Head Injury 

Epilepsy / other seizures 

other Neurological condition 


Chronic Sinusitis 

other Respiratory condition 

Irritable Bowel / Colitis 

Digestive condition 

Skin condition 

Joint Dislocation 

Bone Fracture 



Rods / Pins / Plates / Shunts 





Current Condition

GDPR - The data we collect on you

The personal data we collect will be information relating to your contact details, including name, address, phone numbers and email address. This will be used for appointment confirmations, reminders and cancellations, or if we need to get in touch to rearrange appointments. You can opt out of all emails at any time using the booking system. You can opt in to receive news and updates from us via email. 

We will also collect data relating to your treatments with us, which may include information about lifestyle, and any relevant health issues. 

This data is shared with your therapist(s) and admin assistant. We will only use your data for the purpose for which it was collected, to enable us to administer treatment and provide a professional service.


  • We will retain your data on our secure booking system

  • You have the Individual Rights under the Data Protection act 2018

  • To be informed about the personal data we hold on you

  • To access your personal data

  • To object to the processing of your personal data

  • Restrict the processing of your personal data

  • To rectify your personal data

  • To erase your personal data

You can exercise your Individual Rights at any time without charge. However, if your request is considered repetitive, unfounded or excessive a reasonable administration fee can be charged.

We will take all appropriate technical and organisational steps to protect the confidentiality, integrity, availability and authenticity of your data.


Please Note: Your appointment time has been reserved for you. In courtesy of your therapist & fellow patients, we ask that you provide us with 24 hours notice of cancellation, or a cancellation fee will be charged. Payment for all treatment, whether private or insured, is ultimately the responsibility of the patient. 

I authorise the clinic and its associated therapists to collect my personal and medical information as documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments at any of the contact numbers I have provided above. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Thanks for submitting!

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