hilary grandon please Tel 07779020227 with any queries

PATIENT PRE-CONSULTATION QUESTIONNAIRE

Patients name ______Date ______

Address ______

______Postcode ______

Home phone ______Mobile ______

Work phone ______e-mail ______

Age/DOB ______

Employed______full time parent / part time parent / retired / student / unemployed

GP’s name ______GP’s phone no ______

GP’s address ______

Patient agreement to notify GP of any necessary information Yes / No

Patients medical history please provide details of any recurring or serious illness, accidents or operations (include childhood illnesses, i.e. whooping cough) Approximate dates

______

______

______

______

______

______

______

Allergies ______

Family medical history please provide details of serious illness of parents, siblings and grandparents

______

______

______

______

______

Medication Please provide details of current prescribed medication, herbal medicine, supplements and

approximate length of time taken. Also any long term or strong past medication, inc. repeated use of antibiotics.

______

______

______

______

______

______

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hilary grandon

PATIENT INFORMED CONSENT

I am aware that :-

• occasionally acupuncture may cause small local bruises.

• occasionally needle withdrawal may produce a very small drop of blood.

• cupping (if used) can often cause large areas of redness, (or occasionally bruising) on the skin, which may last for a few days.

• if I do not turn up for my treatment or cancel 24 hours before the

appointment, I will be liable to pay the full fees for the missed appointment.

• if I am late for my appointment my treatment may be cut short in order to

treat further patients on time.

• any information I give my practitioner will be held in strict professional confidence.

• at any stage I may withdraw my consent for a given procedure

• Pregnant patients only:

I am aware that the birth induction treatment may induce a feeling of nausea or faintness.

I confirm that I have read the above, and consent to treatment

Signed ______

Print name ______

Date ______

Please circle or say how you heard of acupuncturehil:

Google search other search engine ______friend referral midwife referral

NCT advert local leaflets/adverts ______other______