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New Patient medical form

If you would like to become a patient of us, please fill out and submit the following medical form and then call us on 079 5078 7254 to book your full holistic examination. Submitted forms without an appointment will not be taken into account.
Please, take a few minutes to fill out the following questionnaire , which will provide all the information needed to us , in order to treat and advise you for a better health achievement.

Please, check our fees on

Confidential medical history questionnaire

Do You Have or Have You Had Any of the Following ?

Anaemia/Blood clotting disorders
Heart condition/Heart attack/Angina
Asthma or other chest problems
Hepatitis B or C
Bad reaction to local anaesthetic
High blood pressure
Rheumatic fever
Liver/kidney problems
Infectious diseases (HIV,etc...)
Treatment that required you to stay in hospital
Other medical issues
Are you taking any medications?

Women only

Are you pregnant ?
Are you taking the contraceptive pill ?
Are you trying to conceive ?
Are you breast feeding ?

Health-related questions

Reason for consultation

Acute medical complaints: where and since when?
Acute dental complaints: where and since when?
Do you have any symtoms related to heavy metals of infected teeth?

Nutritional questions

Do you consume sugar and sugary drinks? If so, which ones and how often / how much?
Do you consume dairy products? If so, which ones and how often / how much?
Do you eat white bread and other white cereal/grain products?
Do you eat meat or sausages? If so, which ones and how much?
Do you eat fish? If so, which ones and how often / how much?

Lifestyle questions

Do you smoke? If so, how often / how much?
Do you consume alcohol? If so, which products and how often / how many units per week?

How many hours a day do you spend with digital media (TV, computer, smartphone, tablet) on average?

Do you use a DECT telephone (cordless) at home or at your place of work?
Do you make phone calls with your smartphone placed next to your ear? If so, how many minutes a day?
Do you have Wi-Fi at home and do you turn it off at night?

How far is the next cell tower from where you sleep, and since when?

Do you have Wi-Fi reception from surrounding buildings or apartments?
Do you exercise and if so, which types of exercise and how often / how much?

How many hours do you sleep on average  each night?

What percentage of your waking hours would you categorise as being stressful?

Clinical  documents

Please upload any x-rays or blood test report you have recently had

Upload File


I hereby confirm with my signature that all the information provided here is truthful and that it is useful to treat and advise me for a better health achievement

I hereby confirm with my signature that I agree with the data collection (photos,x-rays,videos,blood samples) for diagnostic and scientific purposes.

Thanks for submitting!

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