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Patient Form

HOW CAN WE HELP YOU?

 
From 0 to 10, how bad is it? How intense are your symptoms?
No symptoms          Intense symptoms
⓿ ❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾ ❿

What does it feel like? (tick where appropriate) NumbnessSharpTinglingShootingStiffnessBurningDullThrobbingAchingStabbingCrampingSwellingNagging

Impact of your symptoms

 
From 0 to 10 how committed are you to correcting this issue?
Not Committed          Very Committed
⓿ ❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾ ❿
On the arrow diagram above:
(If 2 or more points apply to you, your health is likely represented by this number e.g. If you are experiencing symptoms and taking medication your current health is represented by a 1-3)

HEALTH & ILLNESS HISTORY

Please tick the box beside any condition that you have or have had. AIDS/HIVAlcoholismAnxietyArteriosclerosisArthritisAsthma/AllergiesBack PainCardiovascular IssuesCancerCirculation IssuesChildhood IllnessDepressionDiabetesDigestive Issues(Constipation/Diarrhoea/IBS)Elbow/Wrist/Hand IssuesThyroid IssuesFoot/Ankle IssuesGoutHeadaches/MigrainesHeart DiseaseHepatitisHip IssuesImmune IssuesLymphatic IssuesMultiple SclerosisNeck PainReproductive IssuesRinging in EarsScoliosisShoulder IssuesStrokeTMJ IssuesUrinary IssuesOsteoporosis

ALLERGIES, MEDICATIONS & SUPPLEMENTS