Consultation Form

Hello there – really looking forward to connecting with you. Please take your time to complete this form as fully as possible, aim to invest at least 10-15 minutes of your time to complete it.

Some of the questions may not seem relevant but are really helpful for me to help you so the more detail you can give the better.

All the information you provide is kept securely and in the strictest of confidence.

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Patient Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Number
Email
Date of Birth
Age
Emergency Contact Name
Emergency Contact Phone Number
What are your treatment goals?
How did you hear about the clinic?

Medical History/Lifestyle Questions
Can you provide a brief overview including dates of your medical history, for example any illnesses or surgeries requiring hospitalisation or chronic / acute illnesses you are receiving medication or treatment for:
Please provide details and results of any tests you have had in the last year ? Blood, salvia tests or investigations ?
Please list any medications (including contraception or coil etc) you are currently on detailing the dosage:
Please list any supplements or vitamins you are currently taking:
Do you smoke ? If so how many cigarettes per day ?
Do you drink alcohol ? If so how many units per week ?
Describe how much exercise you do each week ?
How would you describe your diet ?
How would you describe your energy levels ?
Are there any particular times of day when you feel very tired or very energised ?
Do you have any headaches ? If so please describe frequency, type of pain and location on head.
Do you have any ear or hearing issues ? including tinnitus (ringing in the ears), pain or infections.
How would you describe your mood ? Do you suffer from depression ? Do you easily get angry ? Do you worry or suffer from anxiety or mania ? Are you experiencing any mental fogginess or trouble thinking clearly ?
How would you describe your sleep ? Is it easy for you to fall off to sleep ? Do you wake in the night (is it at the same time ?) please detail the typical time you go to bed and wake up ?
Do you dream a lot ? Are they vivid dreams ? Nightmares ?
How would you describe your general / normal body temperature ?
Do you suffer from hot flushes ? Please detail their frequency and whether during the night or day ?
Do you experience night sweats ? Are they throughout the month or only at specific times ?
Do you suffer with any skin conditions ? Dry, itchy, red, pale, spots ?
How is your digestion ? Do you suffer with bloating, gas, nausea, pain, acid or heart burn ?
Do you have regular bowel movements ? Do you suffer from constipation or diarrhea ?
Do you suffer with urine tract infections ? Do you experience bladder pain ? Do you go to the loo at night ?
Do you experience any heart or chest, palpitations, panic attacks, low / high blood pressure ?
Do every experience any dizziness ?
Do you experience cold hands and feet ?
Do you have allergies or asthma ?
Do you every have floaters in your eyes (black spots or strings) ? do you suffer with dry and / or blurry eyes ?
Are you anemic or think you may be anemic ?
Please describe any areas of pain / concern on body ?
If you have a monthly cycle, please describe frequency, flow and length of bleeding ? Do you have any spotting or break through bleeding ? Describe any PMT symptoms you experience ?
If you no longer have a monthly cycle, please detail when it stopped ?
Do you suffer from vaginal pain, dryness or itching ?
Please give details of pregnancies and birth details ?

Let's Connect

Specialising in hormone health for women. Expert in alternative support to the menopause.

Due to demand I had to pause taking on new patient

As promised - quick reel of new clinic layout - tu

Oh my goodness so long since I have posted. Here’s a little update of what I have been up to:-

* The Acupuncture Clinic has been super busy - its been so wonderful to help so many women and see them get better. Unfortunately, as it is so busy I have decided to move to a waitlist for new acupuncture patients for the next few months. New patient slots may come up sooner so definitely do get in touch if you would like to be put on the list. There is a contact form you can use on my website.

* The clinic has had a little change around - giving us more room. Patients have loved it and so do I. I will pop on a little video clip on here so you can see the new layout in all its glory. All patient files are now held electronically which means I can answer any questions you may have faster with easier access to your notes.

*Earlier this month I presented to the amazing practitioners who are part of the fabulous @well.life.tribe about who I am and how I can help women. Very excited to be part of the team going to the @Vervefestival in September.

* Coming soon....The Menopause Herbalist.......due to demand.....helping more women who aren’t able to get to the clinic physically via on-line consultations with herbal prescriptions. There is still work to do on this behind the scenes but I hope to share more with you in the next few weeks. I am so excited to help more and more women and make herbs more accessible to help women feel better.

Do get in touch if you have any questions or I can help in any way.

Emma x

#acupuncture #herbs #menopause #perimenopause #clinic #wellness #welllifetribe #vervefestival #update #hotflushes #herbalmedicine

If you have a private medical insurance policy, yo

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Please do feel free to call to chat more on 01932 901199. My reception team are ready to take your call from 8am to 7pm (Mon to Fri) and 8.30am to 5.30pm (Sat). If you prefer, please do send me an email or you can book directly online here.

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Consultation Form

Step 1 of 3

Patient Information

Medical History/Lifestyle Questions

Informed Consent

Let's Connect

Specialising in hormone health for women. Expert in alternative support to the menopause.