Name

Email Address

Phone Number

Date

Your Address

Your Town

Your County

GP Name

GP Address

GP Town

GP County

Reason for last GP visit

Current prescribed medication or remedies?

Do you eat regular meals?

How is your current physical health?

How much water do you drink?

Do you smoke? Do you smoke?YesNo

How much exercise do you get each week?

Do you drink alcohol? Do you drink alcohol? YesNo

Are you happy with the amount that you drink?

Do you sleep well? Do you sleep well?YesNo

How many hours?

How do you relax?

What are your hobbies / interests?

What would you like to change today?

Do you enjoy your work?

How well do you cope with stress?

How did you hear about our services?

We would like to email you occasionally with our blog or information that we think will be helpful. If you’d rather not be added to our mailing list, please tick. We would like to email you occasionally with our blog or information that we think will be helpful. If you’d rather not be added to our mailing list, please tick. Remove me from the mailing list

I am prepared for this information to be recorded and kept by my therapist together with details of treatment sessions. I am prepared for this information to be recorded and kept by my therapist together with details of treatment sessions. Yes