New Client formPlease complete this before your appointment to save time, thanks Ush Name * First Name Last Name Email * Phone (###) ### #### Date of birth Occupation How did you hear about me? * Word of mouth (friend/whanau) Facebook Google Referral (health practitioner) Other Describe injuries, concerns or issues to address & causes/dates of occurrences if possible Have you had treatment for this particular issue/issues? What are your treatment goals? Health history (tick all that apply) Cancer Headaches/Migraines Arthritis Diabetes Joint replacement/s High/low blood pressure Neuropathy Fibromyalgia/CFS/ME/Long Covid Stroke Kidney dysfunction Blood clots Numbness/tingling Sprains/Strains Any allergies or sensitivities Do you take any medication? If so, please list. You may wish to include supplements if relevant to your visit. I agree that I have completed this form to the best of my ability and agree to inform my therapist if any of this information I have provided changes. * Yes Thank you. I look forward to meeting you soon. Best, Ush
