Medical History FormName*Date of Birth MM slash DD slash YYYY Please provide a brief description of your problem?Has this occurred before and if so when?Are your symptoms worse during the day or at night Night DayIs the problem improving?Does your pain wake you at night? Never Frequently Rarely AlwaysDescribe what aggravates/relieves your problem?Have you had any other treatment for your current problem?Who was the practitioner?Did you find the treatment effective? Yes NoPlease rate the severity of your symptoms-- 10 being the most severe pain --12345678910Could you be pregnant? (Female only) Yes No Does your current problem involve any of the following:Pain in either arm and leg Yes NoTingling in either arm and leg Yes NoNumbness in either arm and leg Yes NoWeakness in either arm and leg Yes No"Weird" sensations in either arm and leg Yes NoDo you currently smoke? Yes NoDo you currently drink alcohol? Yes NoDo you currently take recreational drugs? Yes NoDo you think you have a healthy diet? Yes NoDo you take vitamin supplements? Yes NoDo you exercise regularly? Yes NoPlease list any sports/hobbies you havePlease comment on any signicant surgery and hospitalisationAre you currently taking any form of medication? If Yes please list medications.Do you have any other significant medical history?Have you ever had a car accident? If Yes please describe? Please indicate yes/no to the followingDo you have frequent headaches? Yes NoDo you feel stressed? Yes NoHave you experienced dizziness /vertigo /faints/blackouts? Yes NoDo you suffer from fatigue? Yes NoDo you suffer from night sweats/fever? Yes NoDo your joints swell? Yes NoHave you lost/gained weight in the past year? Yes NoDo you have digestive problems? Yes NoHave you noticed any blood or mucus in your bowel movements? Yes NoDo you suffer from shortness of breath or chest pain on exertion? Yes NoDo you have any pain or increased frequency on passing urine? Yes NoDo you have any unusual lumps/swelling on your body? Yes NoDo you have any problems with hearing? (Including ringing in ears) Yes NoDo you have any problems with smell or taste? Yes NoAre you easily depressed? Yes NoDo you suffer from anxiety? Yes NoDo you have poor sleep? Yes NoDo you have poor sleep? Yes NoDo you have any problems with your vision? Yes NoDo you have poor balance? Yes NoEmail* I consent for my information to be communicated to my GP and/or other relevant health professionals when appropriate.* I give consent I do not consentPhoneThis field is for validation purposes and should be left unchanged.