Holistic Health Questionnaire

Date of possible appointment:

Medical History

Do you suffer from or have:
Do you suffer from pain, illness or discomfort in the following:
Do you take / have?
Do you have bowel movements:
Do you take any of the following?

I have read and understood the above. The details I have given are true to my knowledge.


You are now done.

Please show this to a member of staff.