New client questionnaire Please take the time to complete this questionnaire before your first appointment. New client questionnaireFull nameDate of birthEmail addressTelephone numberPlease list any medications you have taken or are currently taking. This includes vitamins and supplements, birth control and any other therapies.Please list all vaccinations, including any reactions.Please list any illnesses or health issues you have had both past and present, including any hospitalisation or surgeries.Please indicate if any relative (stating their relationship to you) has/ is experiencing any health challenges or concerns.Reason for consultation, how can I help you? I understand that Helen Simm is not a medical doctor and does not diagnose disease conditions. I also understand that anything discussed with Helen is strictly confidential, including my data. Any changes or reductions to medications &/or former treatments are decisions made between myself and my medical doctors/ GP.Submit questionnaire
