test

Your Name (required)

Your Email (required)

Your Telephone Number (required)

Date of Birth

Current Occupation / How you spend most of your time

Do you enjoy your work?

YesNoSome aspects

Your GP name & Practice details?

Are you currently under the care of your GP or other health professional(s) for any health issue(s)?

YesNo

If 'Yes', please give details below

Please list any prescribed or 'over the counter' medications you are currently taking, with an estimation of how long you've been taking them:

Please list any ('non-drug') supplements or remedies you are currently taking, with an estimation of how long you've been taking them:

List any allergies you have:

Have you experienced any significant illnesses / accidents / surgical operations or trauma in the past? If yes, please give details below:

Do any health conditions seem to run in your family? If yes, please give details below:

For the issues you are seeking therapy, please rate your current symptoms on a scale of 1-10, with 1 being virtually no symptoms and 10 being the worst imaginable. Please also add detail of frequency and duration of the problem and how it affects your life:

MAIN ISSUE

Frequency, Duration, Severity (out of 10) and Impact on your life:

Secondary Issue (if applicable)

Frequency, Duration, Severity (out of 10) and Impact on your life:

Third Issue (if applicable)

Frequency, Duration, Severity (out of 10) and Impact on your life:

What (if any) treatments have you previously tried to improve your health? Please tick any you have tried and leave blank any treatments you've not previously undertaken:
Conventional Drug treatmentAcupunctureAromatherapyBody Stress ReleaseBowen TechniqueChinese MedicineCognitive Behavioural Therapy (CBT)Counselling / PyschotherapyFar Infra Red TherapyHomeopathyHypnotherapyNutritional TherapyOxygen TherapyReflexologyReikiSwedish (or similar) Massage

In the box below, please give details of what you eat and drink during an average day - including main meals, snacks and drinks. This can be as detailed as you choose. Please know that this information will be used purely to offer any appropriate recommendations to optimise your health and involves no judgement or criticism of habits or preferences!

What is the biggest result you are seeking through working with us at Unique Perceptions?

List your three most important lifetime goals at this time:

Do you have any problems with breathing through your nose?
(The Airnergy device requires nasal breathing)

YesNo

Do you notice any hypersensitivity to plastic or other substances?

YesNo

How do you like to relax?

Anything else you feel we should know?