Patient First-Visit Health Information

Your full name *

What you like to be called

Day of birth *

Month *

Year *

Email address *

I use this to contact you for any follow-up questions I may have. I will not share this information with any other people.

Full address *

Name and telephone number of GP or surgery *

Primary telephone number *

Your mobile number is preferred to make contacting you easier.

Relationship status *

Occupation *

Do you have a pacemaker or electrical implants? *

No
Yes

Do you have a bleeding or blood disorder? *

No
Yes

Have you ever had a fit/faint, or suffer from epilepsy/seizures? *

No
Yes

Have you got damaged heart valve(s) or are a raised risk of infection? *

No
Yes

Do you suffer from a heart condition or have high blood pressure? *

No
Yes

Do you have asthma? *

No
Yes

Are you pre-diabetic or diabetic? *

No
Yes

Have you had acupuncture before? *

No
Yes

What are you seeking acupuncture for? *

Describe the problem(s) you have that you'd like treatment for.

What is your medical & operation history? *

Do you take any medications or supplements? *

Please provide the name and doses of all medication and for what condition(s).

Do you have any allergies or drug sensitivities? *

If you have no allergies or drug sensitivities, please type no.

Do you smoke? *

No
Yes

Do you drink alcohol? *

No
Yes

Describe your average sleep pattern *

How much frequent exercise do you do? *

Describe your daily/weekly routine you most normally complete.

Do you suffer from regular headaches? *

If so, how often do they occur and for how long?

How much fluid/water do you drink per day? *

Any issues with bowels, digestion, or your kidneys? *

Have you got children, or are you pregnant? *

What are (or were) your periods like? *

Family medical history information

Optional. For example, do any diseases run in your family - for example diabetes or heart disease?

Sign by typing your name *

By digitally signing your name here, you are indicating consent for me to use the information provided above to inform how I should treat you. Please rest assured, your information is not used for anything else.

Heather Adams

Acupuncture & Holistic Therapies in Leamington Spa

Patient First-Visit Health Information