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The Clinics

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The Square
West Meon

Service Information

Storeys Barn Clinic
Mostly Mondays and Wednesdays in West Meon. Other days are available if necessary.
1 hr
More Info
Wickham Wellness
Friday mornings at Wickham Wellness.
1 hr
More Info

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New Patient Health History Form

First name*

Last name*

Address*

Email*

Phone*

Occupation*

Please provide details of any sports / hobbies / your exercise routine*

Do you have any relevant existing medical conditions? *

Are you currently taking any medication?*

No

Yes

If yes, what are they for?

Do you have heart / circulatory problems? *

No

Yes

Do you have high blood pressure?*

No

Yes

Do you get headaches / suffer from dizziness?*

No

Yes

Have you ever been tod you have arthritic joints, osteoporosis or a bone or joint problem that could be made worse through exercise?*

No

Yes

If yes, please provide details.

Please provide details of any medical issues that could affect or contraindicate your treatment

Have you had any recent musculosketal injuries or surgeries?

No

Yes

Are you being treated by another practitioner?

No

Yes

Have you been referred by another practitioner?

No

Yes

What is your main reason for attending?*

How did it happen and when?*

What makes it worse?*

What makes it better?*

Any other info that might be relevant?

Confidentiality statement

All information provided on this form is confidential, and shall not be divulged to any third party without the Patient/Client’s prior consent, in accordance with standard medical practice and the Data Protection Act 2018.

The Data Protection Act 2018 has recently been updated to include the recent GDPR legislation. The personal information collected by Rachel Ulph will include information relating to your name, address, date of birth and wider contact details as well as all information relating your requirements for treatment. This data will only be used for the purposes for which it was collected, to enable Rachel Ulph to continue to treat you with soft tissue therapy. Occasionally it may be necessary to contact you directly regarding your treatment appointments or other matters relating to your treatment. This information will not be shared with any third party under any circumstances unless you have explicitly given your consent to do so. Your data will be securely held for 7 years after the date of your last treatment.

Under the Data Protection Act 2018 your individual rights are as follow;

· to be informed about the personal data stored by this organisation

· to be able to access any of your personal data from this organisation

· to object to the processing of your personal data by this organisation

· to restrict the processing of your personal data by this organisation

· to rectify your personal data held by this organisation

· to erase your personal data held by this organisation

Patient/Client’s consent declaration and signature

The information provided on this form is complete and accurate to the best of my knowledge. I have read the above ‘Confidentiality statement’ and the information pertaining to the Data Protection Act 2018, and hereby confirm my consent to treatment, consent to my details being held by Rachel Ulph for 7 years after the date of the last treatment and under necessary circumstances, consent for Rachel Ulph to contact me directly.

Signature

Sign in the box or use the keyboard to type.

Signature field is empty.

07958 992185

rachel.ulph@gmail.com

West Meon

Hampshire

GU32 1LQ

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