Recent history consultation

Name

Date

YYYY

Are there any particular issues you wish us to address? Please give details

Have you had any recurrence of your former problems? Please give details

Have you experienced any new problems since your last visit? Please give details

Have you had any accidents, falls, injuries, attacks etc, since your last visit? Please give details

Have you consulted another doctor or health practitioner for any of these (old or new) problems? Please give details

Have you had any illnesses recently? Please give details

Have you had any surgery recently? Please give details

Are you taking any medication at the present time?

Change of address (if applicable)

Phone

(###)

###

####

- If x-rays are required, please understand that the fee charged is for taking, processing and reading the films. They remain part of your case files at Hope Spinal Wellness. - Fee for re-examination/consultation and adjustment is £60. If x-rays are required there is an additional fee. - I understand that no accounts are rendered by this centre and my payment at the time of the first treatment will be:

Cash

Card

Cheque

Bank Transfer

I am happy to receive health information and e-chats from Hope Spinal Wellness. We never pass your details onto any advertisers.

Yes

- A Hope Spinal Wellness Privacy Policy Notice is available on our website or by request.

Consent

I HEREBY GIVE CONSENT TO UNDERGO A CONSULTATION AND/OR EXAMINATION

Electronic Signature

Date

YYYY

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Recent history consultation

Your health awaits.