Client Registration Form 1 Start 2 Complete Date Full Name * Contact Number Email Address * Repeat Email Address * Date of birth G.P Name & Contact number Title and Gender Which Hampstead Health Practice Therapy would you like? Medical History Do you smoke ? How many units of alcohol in one week? On a scale of 1 – 10 with 10 being really good. Where would you put your eating habits? What type of exercise do you partake in every week? Are you at a healthy weight? Do you have back, leg or neck pain? Please describe. Are you taking any medication? If so, what is the medication and why is the medication being taken ? Name any health diagnoses you have been given by your G.P or Specialist. Please name the allergies you have been diagnosed with? For Optimum Health What are your health goals ? How are you going to achieve your health goals?
