Living Well Clinic Relief & Recovery From Chronic Pain Book a Free Consultation Private and Confidential Personal Details Name(required) Home Address(required) Date of Birth and Age Home Phone Number Mobile Phone Number(required) Email(required) Occupation Relationship Status Single In long-term relationship Married Separated Divorced Widowed Living Situation Live alone Live with partner or spouse Live with parents Do you have children? Yes No Health Questionnaire Are you currently experiencing any of the following? Have you ever been diagnosed as suffering from any psychological or psychiatric condition? If yes, please give details. Heart problems Yes No Migraine or epilepsy Yes No Physical pain or injury Yes No Specific fears or phobias Yes No If appropriate, have you consulted your GP about the condition(s) for which you are seeking therapy? Yes No Do you suffer with IBS or other gastro-intestinal issues? Yes No Are you currently using any prescription medication? Yes No Do you, or have you ever, used any illegal drugs? Yes No Do you have other health condition(s) that may be relevant? If yes, please give details. Do you suffer with tension in any particular part of the body? Briefly describe alcohol/caffeine intake per day/week, and number of cigarettes smoked per day if applicable. Briefly describe your level of exercise. (Daily or weekly activities) Briefly describe your sleep. (Trouble falling asleep? Waking during the night? Waking early?) GP Details GP Name(required) GP Practice Phone Number(required) GP Practice Email GP Practice Address(required) The information given above and throughout this consultation is, to the best of my knowledge, full and correct. (required) Submit
