If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Patient’s Name * Telephone * Email * Date of Birth * Address * Postal Code * Sex: M/F * MaleFemale Occupation Relationship Status Children GP’s name and telephone * MAIN COMPLAINTS/PRESENTATION OF SYMPTOMS: Nature/first onset/ progression/ duration/ factors affecting: aggravating/relieving/pain Diagnosis / Treatment/Medication DRUG HISTORY Laxatives Painkillers Herbs Supplements Other alternative treatment Pill/HRT Immunizations Recent tests LAST MEDICAL HISTORY Childhood diseases Other illnesses Accidents Operations Hepatitis / Jaundice Diabetes Glandular fever TB Asthma Eczema Allergies Other NERVOUS SYSTEM Energy levels: 1 –10% Stress levels Memory / mood Sleep Temperature: hot/cold Headache Deafness/ Tinnitus/dizziness Fainting / Weakness Paresthesia (pins and needles) RESPIRATORY SYSTEM Colds Sore Throat Ear infection Catarrh Cough/phlegm Chest congestion Chest infections Breathing difficulties GASTRO-INTESTINAL TRACT Appetite / Weight gain Mouth / dental Nausea / Indigestion Vomiting Bloating Flatulence Stools: frequency/ loose & formed / hard and formed / colour / bleeding CARDIO VASCULAR SYSTEM Chest pain Palpitations Oedema Varicose veins / haemorrhoids / DVT Anaemia Circulation: hands / feet URINARY SYSTEM Infections Pain Frequency Problems of flow Quantity Colour GYNAECOLOGY / REPRODUCTIVE SYSTEM Date of last period: Days of period length: Cycle length: Flow / colour: PMT Pregnant / trying Contraception Pregnancies / Abortions Miscarriages Infertility / Impotence Discharge/Thrush Sexual history / STDs Menopause MUSCO-SKELETAL SYSTEM Pain / stiffness: neck / shoulders / knees / lower back Swollen joints Muscle cramps Arthritis GENERAL: Lymph: oedema / nodes swollen Skin: rashes / dry / oily / allergies / infections Hair: Eyes: Nails: DIET/NUTRITION Vegan / Vegetarian / non-dairy / meat / Soya: Breakfast: Lunch: Dinner: Drinks / Snacks LIFESTYLE FACTORS Smoking Drinking Recreational drugs Exercise Work Emotional and Social Factors: Significant events weighing on you emotionally? Type of relaxation methods and frequency: CLINICAL EXAMINATION Tongue: Blood Pressure: Weight: Height: Physical appearance:
