New Client Form
TICK ALL THAT APPLY
- STEP 1
- YOU & FAMILY
- OTHER ISSUES
DATE OF BIRTH
NUMBER & AGES OF CHILDREN
HOW DID YOU HEAR ABOUT LIFE RIGHT (IF FROM A PERSON, PLEASE GIVE THEIR NAME)
YEARS IN CURRENT JOB
PREVIOUS OCCUPATION IF LESS THAN 2 YEARS
HEALTH DETAILS (PLEASE COMPLETE IN FULL)
NAME OF GP
DOES YOUR GP KNOW YOU ARE ATTENDING LIFE RIGHT?
WHAT MEDICATION ARE YOU CURRENTLY TAKING?
WHAT MEDICATION WERE YOU TAKING BEFORE BUT ARE NO LONGER?
BROKEN BONES IN THE PAST
ANY PREVIOUS ROAD TRAFFIC ACCIDENTS? (INC. DATES)
PLEASE LIST ANY OPERATIONS OR HOSPITALISATIONS IN LAST 10 YEARS (INC. DURATION)
ANY PREVIOUS X-RAYS
PLEASE DETAIL FROM CHILDHOOD TO PRESENT DATE ANY EVENTS, SITUATIONS, PEOPLE OR TRAUMA YOU FEEL MAY BE SIGNIFICANT IN HOW YOU ARE FEELING TODAY (WITH DATES IN A TIMELINE LIST) (inc. hospital visits or long periods of antibiotics)
THE NEXT SECTION IS FOR WOMEN ONLY. PLEASE GO TO NEXT SECTION IF THIS DOES NOT APPLY
LAST CERVICAL SMEAR
LAST BREAST EXAMINATION
DO YOU CHECK YOUR BREASTS REGULARLY?
LAST MENSTRUATION PERIOD STARTED
PERSONAL INFO (CONTD)
DO YOU SMOKE
IF 'YES', HOW MANY PER DAY?
FOR HOW MANY YEARS?
DO YOU EXERCISE?
TYPE OF EXERCISE?
YOUR HEIGHT IN CMS
YOUR WEIGHT IN KGS
HAVE YOU OR A FAMILY MEMBER SUFFERED WITH ANY OF THE FOLLOWING CONDITIONS
PLEASE TICK ALL THAT APPLY
ANY TYPE OF CANCER
CHRONIC PAIN (LONGER THAN 3 MONTHS)
DIABETES (TYPE I OR II)
HEART DISEASE / HIGH CHOLESTEROL
ASTHMA / COPD
MIGRAINES / HEADACHES
HYPERTENSION / HIGH BLOOD PRESSURE
DIGESTION / ULCERS
IBD / CROHN'S / COLITIS
BLADDER / UTI'S
OBESITY / ANOREXIA
DEPRESSION AND/OR ANXIETY
ANY OTHER PROBLEM
ARE YOU CURRENTLY PREGNANT?
ARE YOU CURRENTLY EXPERIENCING ACHES OR PAINS? PLEASE DESCRIBE IN AS MUCH DETAIL AS POSSIBLE
PAIN LOCATION AND TYPE
PLEASE SCORE THIS 1 - 10, 10 BEING THE HIGHEST LEVEL
PLEASE READ THESE STATEMENTS AND ONLY CHECK THE ONES THAT REFLECT HOW YOU CURRENTLY FEEL
I think consistently negatively
I often jump to the wrong conclusions
I tend to take things personally
I have an inability to cope
I experience severe inner conflict
I have had a nervous breakdown
I resent taking advice
My issues are just a habit
I do not like myself
I have self harmed
I have felt/feel suicidal
I don't like how I see myself
My issue affects my sexual relationships
I dwell on the past
I have feelings of guilt
I have feelings of frustration
I have feelings of grief or loss
I have feelings of rejection
I have feelings of general anxiety
I have feelings of loneliness
I want someone to listen in a non‐judgemental way
I have unresolved traumatic experiences
I have an eating concern
I suffer from PMS
I have work/school worries
I have a fear or phobia I would like to rid myself of
THE SYMPTOM I WOULD MOST LIKE TO WORK ON IS...
THIS IS APPARENT IN THE FOLLOWING SITUATIONS...
AT THE MOMENT, I WOULD SCORE IT AS (1-10). (1=as good as it can be / 10=as bad as it can be)
OTHER TREATMENT I HAVE RECEIVED CONCERNING THIS ISSUE
I WOULD ALSO LIKE MY PRACTITIONER TO HELP ME WITH OTHER ISSUES AS SHOWN BELOW
TICK ALL THAT APPLY
BEFORE THE AGE OF 18, DID YOU EXPERIENCE ANY OF THE FOLLOWING
PLEASE TICK ANY THAT APPLY
This form applies to all forms of treatment administered at Life Right Practice -‐ all referred to under the general heading of treatment Prior to formal commencement of treatment I, the client, understand that... Treatment will require my active participation & commitment to achieve the best outcomes Treatment may at times be uncomfortable or present slight pain and I agree to discuss this with my practitioner It will be beneficial for me to work on goals & objectives as recommended by my practitioner(s) The importance of being honest & providing accurate feedback to help continue my treatment plan Whilst the practitioners will always try & provide an indication of treatment plan duration, this cannot be definitive until all issues have been presented or identified It may sometimes be necessary & beneficial to me that I am referred to more than one practitioner to best resolve my issue(s) If my presenting issues have been apparent for longer than 3 months they may change or become worse for a short time Sometimes the presenting issue is not the cause of what is happening to me, which may require that we look at other aspects. It is my responsibility to disclose all relevant information & withholding anything whether intentionally or unintentionally can affect my treatment Based on what I tell you concerning my presenting issues or via test results, nutritional supplements may be discussed to help with my overall wellbeing. If I choose to include these, I agree to read the label and advise my GP and any other healthcare professional. I accept full responsibility for any dosage and agree to discuss with my practitioner should I change this. I agree to inform my practitioner & GP of any other nutritional supplements I take that have not been discussed with a Life Right Practitioner. In some cases, to diagnose a condition, an examination where the practitioner needs to see my skin may be required. With my approval, my records may be passed to other practitioners to keep them involved and in knowledge of my progress. Life Right may at times contact me via email, text or social media with details of services etc. (I can opt out at any time) Life Right does not disclose my details to any other person or organisation without my consent Life Right may use any verbal or written feedback I provide for marketing purposes without disclosing my full name I will be charged the full session fee if I fail to attend, or cancel an appointment within 48 hours. I consent for any payment details provided to be used to cover this cancellation charge. In the event of no payment details being available, I agree to clear the outstanding amount before further treatment commences.
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