Please complete this form in as much detail as you can.

If a section or question is not relevant to you then leave it blank.

Any symptoms, however small, are helpful for me to build up a picture of your issues.

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The form should only take you between 15-45 minutes.

Don't let the form filling be a barrier to getting help. If you don't feel able to fill out this form, then please get in touch and we can do it together over the phone.

 

Don't worry if you forget something, just make a note to mention it when we speak.

Approximate dates are perfectly acceptable.

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This form is not used to 'diagnose' you in any way. It is used to benchmark your symptoms at the start of this process so we can track improvements and changes. It is also useful to validate my findings and to understand where your priorities for clearing are.

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All the information that you share on this form is private and confidential.

 

Thank you again for contacting me and remember that improving your health does not have to be an up­-hill struggle.