Your E-Mail Address: *
Telephone No: *
Your Mobile:
Age: *
Marital Status: *
GP Practice: *
Reason for treatment: *
If YES, please give details:
If YES, please give details:
If YES, please give details:
If YES, when and where, further details:
If YES, please give details:
If YES, please give details:
If YES, how many weeks?
If YES, how recent are they?
If YES, please give details:
If YES, please give details:
Please give further details about any questions that you answered YES to:
What is your occupation (it does not need to be paid)? *
How much free time do you have per week? *
What are your hobbies or creative interests? *
How would you define your sleep pattern? (e.g. how many hours per night) *
Do you have a balanced diet? (e.g. how much processed food do you eat per week, how much fruit and vegetables) *
How much caffeine do you drink per week? *
If yes, amount per day:
If yes, amount per week:
Do you have any dietary problems? (e.g. overeating, intolerances, binging) *
How much exercise do you take per week? *
Any other relevant information?
Print Name: *