Holisticare New Patient Form

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Holisticare New Patient Form - Remote Patients

Please complete this form before your remote consultation. Thanks, Nikki

Consent: I consent to my details being added to the Holisticare database. For patients receiving Zoom or phone consultation: I understand that any advice given remotely is based on the information that I provide, and is limited as no physical examination has been carried out. I understand that this advice does not replace medical attention and that I am responsible for seeking medical help if required. Please sign below if you consent to a remote consultation from Holisticare. *

Title *

Other - Please specify

Pronouns:

Full Name *

Preferred name (if different from above)

Date of Birth *

Full Address *

Postcode *

Home Phone Number *

Mobile Phone Number *

Email Address *

Is it ok for us to email you occasionally with information and offers? We will never share your email with any third party. *

Yes

Occupation *

Name of Emergency Contact *

Relationship *

Contact Number *

Referral Source *

Tell us how you heard about us

*Name of Referrer, Networking Group, Event or Workshop

Please tell us the name of the person who recommended us or the name of the networking group, workshop or event where you met us. If you found us from an internet search, please tell us what you searched for. Thank you

Doctor's Surgery *

Name and Address

History of Current Condition *

Your diagnosis, symptoms, etc. Please include how and when your condition started, any medical or complementary treatment received.

What is your goal of treatment? *

Past Medical History *

Please include ALL hospital admissions and treatments, breaks, sprains, falls, illnesses, disorders, conditions, accidents, injuries, operations, childbirths etc. past and present, however insignificant they may seem. Any/all aches and pains. Please include the year or your age and which side of your body was affected if you remember. Please also include any mental health or addiction history e.g. anxiety, depression, alcoholism etc.

Current Medication *

Please list all medications currently taken. If you do not take any medication please state NONE.

Do you have any problems sleeping? If yes, please give details. *

Do you do any regular exercise? Please give details *

Alcohol intake: *

Diet - eg details of any restrictions, balanced, healthy? *

How do you relax? *

How would you describe your stress levels? *

Are you allergic to anything? Please give details below. *

Are you pregnant? *

Yes

Have you taken steroid medication in the last 2 years? *

Yes

Do you suffer from fainting or blackouts? *

Yes

Do you suffer from headaches? *

Yes

Do you have a cardiac pacemaker? *

Yes

Do you smoke? *

Yes

Have you had any problems with high or low blood pressure? Please give details below. *

Are you diabetic? *

Yes

Are you epileptic? *

Yes

Are you asthmatic? *

Yes

Have you had any recent infections? *

Yes

Have you had any unexplained weight loss? *

Yes

Are you suffering from any symptoms of Covid-19 at the moment? *

Yes

Do you have any bladder or bowel symptoms? Please give details below. *

Do you have pins and needles or numbness anywhere? Please give details below. *

Any Other Relevant Information:

(Eg: Other medical history not covered? Hereditary conditions? Any major causes of stress? Recent bereavements? Take care of children, elderly people or any people with disabilities, illness etc.? Financial concerns? Any religious or cultural requirements?)

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