New Patient | biohealth-uk.com

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 020 7223 5114 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 https://www.biohealth-uk.com/fees

Confidential medical history questionnaire

Full Name

Occupation

Phone

Date of birth

Address

Your GP's name and address

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

Anaemia/Blood clotting disorders

Yes

Heart condition/Heart attack/Angina

Yes

Arthritis

Yes

Asthma or other chest problems

Yes

Hepatitis B or C

Yes

Bad reaction to local anaesthetic

Yes

High blood pressure

Yes

Diabetes

Yes

Rheumatic fever

Yes

Epilepsy

Yes

Liver/kidney problems

Yes

Infectious diseases (HIV,etc...)

Yes

Cancer

Yes

Treatment that required you to stay in hospital

Yes

Allergies

Yes

Other medical issues

Yes

Are you taking any medications?

Yes

Women only

Are you pregnant ?

Yes

Are you taking the contraceptive pill ?

Yes

Are you trying to conceive ?

Yes

Are you breast feeding ?

Yes

Health-related questions

Reason for consultation

Acute medical complaints: where and since when?

Yes

Acute dental complaints: where and since when?

Yes

Do you have any symtoms related to heavy metals of infected teeth?

Yes

Nutritional questions

Do you consume sugar and sugary drinks? If so, which ones and how often / how much?

Yes

Do you consume dairy products? If so, which ones and how often / how much?

Yes

Do you eat white bread and other white cereal/grain products?

Yes

Do you eat meat or sausages? If so, which ones and how much?

Yes

Do you eat fish? If so, which ones and how often / how much?

Yes

Lifestyle questions

Do you smoke? If so, how often / how much?

Yes

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

Yes

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?

Yes

Do you make phone calls with your smartphone placed next to your ear? If so, how many minutes a day?

Yes

Do you have Wi-Fi at home and do you turn it off at night?

Yes

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?

Yes

Do you exercise and if so, which types of exercise and how often / how much?

Yes

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

Signature

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

Your Signature

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