CITY BACK PAIN CLINIC

Date __________________

Your Surname  __________________________ Your Forename _____________________

Your Address    _____________________________________________________________________________
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Your Employment        _________________________________________________________________________

Your Work Telephone  ______________________________

Your Mobile ________________________

Your Email   _________________________________________________________________________

GP Name       _______________________________________

GP Address
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GP Telephone _______________________________________

If you could take the time to simply tick the information below and print this form off 
and bring it with you on your first consultation and treatment it would help me greatly 
to save time and to tailor a specific treatment plan for your individual needs. 
Thank you, Chris Curtis MCSP
 
 
When was your last physical examination by a doctor or GP?    _______________________
Have you had any operations?  Yes / No   If yes when please?  _______________________
Last Gynaecological examination (female) Yes / No  If yes when please?________________
Last Prostate Examination (male)     Yes / No    If yes when please? ___________________
Do you have any allergies to food or drugs?  Yes / No    
Have you suffered a stroke?     Yes / No       If yes when please?______________________
Has anybody in your family suffered from a stroke?  Yes / No   
Do you have High blood pressure?   Yes / No
Do you have diabetes?   Yes / No
Have you ever been diagnosed with cancer?  Yes / No
Are you seeing any other Doctors or Therapists?  Yes / No
Have you ever had a car crash? Yes / No     If yes when please?______________________
Are you taking any medication?  Yes / No     If yes please list below ________________
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