Call us on 0151 236 6578
Home
About Us
Treatments
Blog
Special Offers
Contact Us
Testimonials
View Practice
Your Medical History
Please tick any of the following which apply to you
AIDS
Allergies
Anaemia
Arthritis
Artificial heart valve
Artificial joints
Asthma
Blood disease
Bruise easily
Cancer
Chemotherapy
Diabetes
Dizziness
Drug addiction
Emphysema
Excessive bleeding
Fainting
Glaucoma
Heart conditions
Heart lesions (congenital)
Heart murmur
Heart surgery
Hepatitis A
Hepatitis B
Hepatitis C
High blood pressure
HIV positive
Jaundice
Jaw / joint pain
Kidney disease
Liver disease
Mitral valve prolapse
Nervousness / Depression
Pacemaker
Pregnant
Radiation (neck/head)
Respiratory problems
Rheumatic fever
Rheumatism
Scarlet fever
Seizures
Stomach problems
Stroke
Thyroid disease
Tuberculosis
Ulcers
Venereal disease
Please specify any other problems that you may suffer from:
Are you currently receiving treatment from your doctor?
If yes, what for?
Are you currently taking any medication?
If yes, please give details below:
Do you have any allergies to Latex, foods or any other substances?
If yes please specify
:
If you smoke, how much do you smoke in a day?
If you drink Alcohol, how much do you drink in a day?
Please provide the following details of your doctor:
Doctors Phone Number:
Your Name:
Your Email address
Please contact us for a FREE consultation and top tips
Your Enquiry