Personal details

Title *

First Name *

Last Name *

Date of birth *

Gender *

Phone *

Email *

Address

Street Address *

City

State

Country

Postal code

Medical History

Are there any diagnosed medical conditions? *

If yes, then please tell us which medical conditions

Do you use any medication regularly? *

If yes, what medicines or supplements do you take?

Do you have any known allergies? For example, foods, animals, materials etc. *

Please list any previous surgical operations or hospital admissions, together with dates (include any accidents/fractures/trauma):

Are you a smoker? *

Are you now on, or have you ever taken contraceptive pills? If so, for how many years? *

Are you now, or have you ever been on hormone replacement therapy (HRT) If so, for how long? *

Are you pregnant or might be pregnant? *

Are you currently breastfeeding? *

By booking and attending your appointment, you confirm that you have read, understood, and accepted these terms and conditions.

For questions or additional information, please contact Back to Balance Test.

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