Welcome to Escapada Health

Please fill in the following form with as much information as you can.
We look forward to looking after you.

Name

First Name

Last Name

Date

YYYY

Please give detail of past medical/surgical history

Medication

Please specify any regular medication including supplements or oral contraceptive pill. If none, please enter 'none'

Presenting Complaint/ issue

Please provide as much information as possible, for example: Duration / Location / Frequency / What makes it worse or better

Digestion

Digestion: How would you describe your diet?

Any imbalances within your digestion?

If yes, please describe

Any food intolerances/allergies

If yes, please specify

Women's Health (if applicable)

If applicable, please provide more information: Cycle/ Duration (how many days do you bleed / Flow/ Any clots/ Pain / Do you suffer from PMT (pre menstrual tension) / discharge / pregnancies / OCP

Are you post menopausal?

If yes, please provide more information: How many years post menopausal? How was your menopause (symptoms, severity) are you still having symptoms etc.

Anything else that you feel we should know before you start your treatment with us?

Welcome to Escapada Health

Please fill in the following form with as much information as you can. We look forward to looking after you.

Please fill in the following form with as much information as you can.
We look forward to looking after you.