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. 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
Full Name *
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. *
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
Doctor's Surgery *
Name and Address
History of Current Condition *
Please include how and when your condition started, any medical or complementary treatment received, and any medicines taken.
Past Medical History *
Please include any hospital admissions and treatments, breaks, sprains, physical or mental traumas, bereavements, accidents, falls, childbirth etc. Please include rough dates.
Current Medication *
Please list all medications currently taken. If you do not take any medication please state NONE.
Are you allergic to anything? Please give details below. *
Are you pregnant? *
Have you taken steroid medication in the last 2 years? *
Do you suffer from fainting or blackouts? *
Do you suffer from headaches? *
Do you have a cardiac pacemaker? *
Do you smoke? *
Have you had any problems with high or low blood pressure? Please give details below. *
Are you diabetic? *
Are you epileptic? *
Are you asthmatic? *
Have you had any recent infections? *
Have you had any unexplained weight loss? *
Are you suffering from any symptoms of Covid-19 at the moment? *
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. *
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