Please take your time filling in this form. 

Details of the form are important. Put in what you can remember, it's ok if you can't remember everything, however small fractures or memorable knocks are still relevant even if you think they are not. I've seen fractured toes from 3 years of age affecting adults up to 40 years later

Name *
Phone number *
Phone number
Or if you prefer please state 20-30. 30-40. 40-50. 50-60 etc
Please give a brief overview of the issue(s) that you are seeking help with
Detailed History
Have you had recent surgery or needed to visit your GP in the last 6 months? *
Have you had any operations or significant traumas in the past? *
Traumas include memorable falls, shocks, emotional periods or anything that stands out in your memory
Have you broken or fractured any bones?Or had any significant/memorable traumas? including minor/potential fracture - Please list below *
(toes, fingers, tail bone, ribs, collarbone, heavy falls as a child, falling from a tree etc)
Have you had any road traffic accidents? How long ago? *
Driver, passenger, pedestrian, cyclist or motorbike
Do you wear orthotics
If yes please detail
Additional Information
(trouble sleeping, grinding teeth, jaw tension in the morning. Easy-going or stress-head?)
Are you currently taking any medication or just coming off medication? *
Are you diabetic, have high or low blood pressure or ever feel faint or dizzy? *
Do you have any of the following? *
(women only)
Do you have any conditions that will prevent you from performing movements/exercises that may elevate your heart rate? or have you been advised by a GP to avoid any specific activities? *
By signing this you agree the above information is correct and if there is any changes to your health you will notify me accordingly. *
By signing this you agree the above information is correct and if there is any changes to your health you will notify me accordingly.
Today's Date *
Today's Date
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**Due to the (GDPR) General Data Protection Regulation commencing on 25th of May 2018, by signing this form you are giving permission for the details of this form to be stored. The purpose of this form is to obtain all relevant information about you, to assist you with the services provided by Anthony Claffey Therapeutics. This information will only be stored for this specific purpose and will not be outsourced to any marketing/media company or used for marketing or promotion. Your details will be used in a booking system where you will receive appointment notifications, reminders and receipts. Your email/phone will be used as mode of communication for appointments/bookings and for sharing information material that may be discussed with you while attending this service. Our Privacy Policy can be viewed here:  **    

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