Confidential Questionnaire

Welcome to Part One, Confidential Questionnaire - 12 August 2020

Please complete Part One, before moving on to Part Two.

Now to begin this questionnaire, fill in your contact details below and press the Next button.

Full Name
Your Email
1. Home Address
2. Date of Birth
3. Age
4. Marital Status
5. Children
1 out of 5
6. Doctor’s Name / Address
7. Experience of therapy
8. Purpose at that time
9. Did you have a successful outcome?
2 out of 5
10. Purpose of this consultation
11. What do you feel about this issue?
12. How is it affecting your quality of life?
13. Who are you doing this for / Do you want to be here?
14. What do you hope to achieve?
15. Have you any apprehensions about therapy?
16. Have you any questions?
3 out of 5
17. Please specify if you are taking any drugs or medications / recreational drugs?
18. Do you suffer with any of the following:
19. Do you have a fear of lifts or escalators, water or heights?
20. Do you have a high level of stress in your life? Explain
4 out of 5
21. Your Height / Weight
22. Do you Smoke / Drink – Quantities per week?
23. Do you Exercise - How often and what per week?
24. Do you find it difficult to relax?
25. Where would you go to relax? - Seaside, countryside, bedroom etc
26. What are your favourite hobbies?
27. How did you find out about this therapy?
5 out of 5