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Background Health Form

Note: all information is confidential

Please fill in the form before your first consultation, in electronic form and by email.

What is this form for?

The information you provide here will help us to understand how you see your problem, what type of approach is likely to be of most benefit for you and may help us when deciding the practitioner most likely to be effective for you. Your diagnosis or treatment is not decided on the basis of this form. All patients are seen as individuals and will be given personal one-to-one attention from their first consultation onwards.

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If you already know which of the New Medicine Group you are to see, please write the practitioner’s name in the box below:

Name of NMG practitioner
Your Title *
Firstname *
Surname *
Date of birth *

Your details – please complete all questions

Address including Postcode *
Home Phone *
Work/day Phone *
Mobile Phone *
Email *
Accessibility
Professional status/Occupation *
Relationship status/Children *
Approx height and weight *
If you have been given a diagnosis by a doctor, please state
GP’s details
May we contact your GP?
 yes no

What is bothering you?

Main health problem
Other complaints

Personal History

Major medical events and problems in your childhood and adult life
Blood Group
Current prescribed medication (inc contraceptive pill) or self-prescribed supplements
Major causes of illness and death in your family
Hospitalisation, operations, injury, shock, trauma, etc
Known or suspected allergies or intolerances

Previous Treatment: Please list any treatments you have had in the past

Treatment

Your view of your health

How would you rate your current overall feeling of wellbeing, on a scale of 0-6?
0 is the very best you can imagine
6 the lowest you can think of

Your current wellbeing rating is
 1 2 3 4 5 6

We have a wide range of approaches available in the New Medicine Group, so it helps us to know how you view your health problem. Which of the areas below would you say attention should be focused on.

Biochemical (to do with e.g. diet, toxicity, deficiencies, allergy, intolerance, hormonal imbalance)
 no yes yes, most important
Structural (to do with e.g. posture, injury, strain, muscle tension, muscular weakness, overuse, repetitive strain)
 no yes yes, most important
Stress (to do with e.g. shock, conflict, work-life/rest imbalance, life events, mental or emotional issues)
 no yes yes, most important

Your empowerment level

“What are you prepared to do to stop your health problems affecting your life in the way they do now?”

Indicate how strongly you agree with these statements with a number from 0-6.
0 = agree very strongly and 6 = totally disagree.

I am willing to:

Make significant changes to help myself
 1 2 3 4 5 6
Work with my practitioner(s) to get results
 1 2 3 4 5 6
Change negative habits
 1 2 3 4 5 6
Change the way I eat
 1 2 3 4 5 6
Exercise more or differently
 1 2 3 4 5 6
Learn effective mind-body relaxation skills
 1 2 3 4 5 6
Commit 5% of my time to getting and staying well
 1 2 3 4 5 6
I know I will need a lot of help for change to be possible
 1 2 3 4 5 6
I believe it will be hard for me to make any changes
 1 2 3 4 5 6
I know I am not able to make any changes
 1 2 3 4 5 6

If you have some idea of what might help you and what wouldn’t, please say more below:

 

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