Have you been in any road traffic accidents? If yes, please provide dates, information and injuries sustained *
When did you last receive an X-ray and what was it for? *
Do you smoke or vape? * please select Yes No
Please detail your exercise regime over the course of a week *
What medication have you stopped taking in the last 12 months? *
What medication are you currently taking? *
Any form of cancer * Please select None Me A family member Both
Neurodegenerative disorders * Please select None Me A family member Both
Epilepsy * Please select None Me A family member Both
Addiction * Please select None Me A family member Both
Heart Disease or High Cholesterol * Please select None Me A family member Both
Migraines / Headaches * Please select None Me A family member Both
Liver Issues * Please select None Me A family member Both
Irritable Bowel / Chrons / Colitis * Please select None Me A family member Both
Obesity / Anorexia / Bulimia * Please select None Me A family member Both
Depression and/or Anxiety * Please select None Me A family member Both
Chronic Pain lasting > 3 months * Please select None Me A family member Both
Diabetes (type 1 or 2) * Please select None Me A family member Both
Arthritis * Please select None Me A family member Both
Endocrine irregularities * Please select None Me A family member Both
Asthma / COPD * Please select None Me A family member Both
Hypertension / High Blood Pressure * Please select None Me A family member Both
Digestive Problems / Ulcers * Please select None Me A family member Both
Bladder issues / UTI * Please select None Me A family member Both
Skin complaints * Please select None Me A family member Both
Psychiatric Disorders * Please select None Me A family member Both
Serious Illness * Please select None Me A family member Both
Are there any other issues for either you or a family member not covered in these questions? *
Are you currently pregnant * please select YES No
have you experienced physical abuse? * please select YES No
have you experienced sexual abuse? * please select YES No
have you experienced substance abuse? (inc. alcohol) * please select YES No
have you been affected by either poverty or unemployment in the family? * please select YES No
have you experienced a lack of affection? * please select YES No
have you experienced neglect? * please select YES No
have you witnessed abuse? * please select YES No
have you experienced parental divorce? * please select YES No
have you experienced the death of a parent? * please select YES No
have you experienced psychological or emotional upset? * please select YES No
have you experienced criminal behaviour (either you or someone close)? * please select YES No
Please tell us what treatment, counselling or therapy you have received in your past and how it (if it did) helped you *
Please provide a timeline from any childhood events, situations, people or trauma you feel may be significant in how you are feeling today. This can include hospital visits or long periods of antibiotics *
So our therapists can understand what you are currently experiencing, please describe everything you are feeling now *
What help would you like from us? What are your goals from coming to see us? *
Who completed this form? *
I consent to having Life Right UK Limited and this website store my submitted information so they can respond to my query. I also confirm the information I have provided is correct to the best of my knowledge and agree to inform Life Right should any element (including taking medication) should change. I confirm I have read the terms and conditions on the website and agree to these. * please select I AGREE
