Confidential Questionnaire

Welcome to Part One, Confidential Questionnaire - 25 May 2020

Please complete the questionnaire below and when complete, press the submit button.

Full Name
Your Email
Home Address
Date of Birth
Marital Status
Doctor’s Name / Address
Experience of therapy
Purpose at that time
Did you have a successful outcome?
Purpose of this consultation
What do you feel about this issue?
How is it affecting your quality of life?
Who are you doing this for / Do you want to be here?
What do you hope to achieve?
Have you any apprehensions about therapy?
Have you any questions?
Please specify if you are taking any drugs or medications / recreational drugs?
Do you suffer with any of the following:
Do you have a fear of lifts or escalators, water or heights?
Do you have a high level of stress in your life? Explain
Height / Weight
Smoke / Drink – Quantities per week
Exercise - How often and what per week?
Do you find it difficult to relax?
Where would you go to relax? - Seaside, countryside, bedroom etc
What are your favourite hobbies?
How did you find out about this therapy?

Thank you for completing this questionnaire. Please now continue to complete part two: Confidential Mental and Physical Health Scoring