Biosound Medical Questionnaire This questionnaire requires completion prior to any appointments. We ask you kindly to assist us by filling in the following form. Contact Us Name * First Last * Last Address (including postcode) * Email * Phone * Date and place of Birth (please include time if known) * Mothers date of birth * Fathers date of birth * Partners (or ex) date of birth * Children(s) date of birth * Siblings date(s) of birth * Medical Details Do you have a regular G.P or do you visit a Homeopath or Other? Please give a general description of your problem * Are you on any medication? * Do you take any Vitamin or Mineral supplements? General Questions: Do you have, or have you ever had any of the following? Digestive Problems - i.e. diarrhoea, constipation, bloating * Food, Chemical, or Animal allergies * Circulation Problems - i.e. cold hands or feet * Varicose Veins * Joint problems with Hips, Knees, Elbows, Neck etc * Bowel or Bladder problems/haemorrhoids * Stomach Problems/Ulcers * Heart Conditions * Lung Conditions * Throat Problems/Thyroid/Mucussy Throat or Nose * Sinus Problems/Hay Fever * Headaches or Migraines * Eyesight Problems * Hearing Problems * Emotional Status/Stress - i.e. Job, Relationship, General * Have you had any major accidents or operations? * Do you smoke? If so, how many per day? * Are you taking any kind of drugs other than medication? * Do you have a higher than average consumption of alcohol? * Any history of Epileptic fits, Seizures, or Strokes? * Do you have a PaceMaker? * Are you pregnant? * Emotional Problems Do you suffer from stress? Please give some details about your type of work, your lifestyle, and if appropriate; any information you consider relevant regarding your family and personal relationships. * All answers given are in the strictest confidence. The practitioner is not medically qualified thus is unable to make a medical diagnosis. This treatment should not be used to replace any mainstream medical intervention if that is required. I confirm that the information I have provided on this form is true and accurate. I agree to my health record and other information being securely and confidentially held by the therapist for a minimum of seven years under the EU GDPR 2018 compliance guidelines. I give permission for my results to be discussed with other colleagues or professionals if deemed appropriate; whilst maintaining confidentiality at all times. I hereby confirm that i have read and understood the above points and am happy to proceed with the sound therapy treatment. Signed * Date * If you are human, leave this field blank. Submit
