Dr Lauren Downing - Client Submission Form

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Address

City

Postcode

Additional Information

Date of Birth

GP Surgery and Doctor's Name (if known)

Emergency Contact Name

Emergency Contact Phone

Occupation

Health Information

How is your body physically? Please describe any current symptoms or pre-existing medical conditions

Describe any significant past history concerning your physical body

(Physical trauma, motor vehicle accidents, broken bones, ligament tears, falls, surgical procedures, hospitalisation, cancer, childbirth, loss of consciousness)

Describe any significant past history concerning your mental and emotional life

(major life events, stresses, traumas, crises, any professional diagnoses, and how they were managed)

How is your mental and emotional life currently?

(please include any current mental health challenges, diagnoses, stressors)

Do you take any medication (over the counter or prescribed), supplements, recreational drugs, smoke or drink alcohol?

Do you have any allergies?

Current/past practitioners & helpfulness with regards to your current health concerns

Is there any other information relevant to your care that has not been covered or any questions for your practitioner?

Consent

I consent to my chiropractor contacting my GP if clinically appropriate, and to relevant health information being shared for the purposes of safe and coordinated care.

Signature *

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Personal Information

Additional Information

Health Information

Consent

Signature *

Thank You!