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Health Questionaire

Answer the questions in the form below to get a personalised recommendation on the treatment we believe will suit you best.
*Disclaimer: If you are in immediate danger, please contact your doctor

Whats Your Name?(Required)

First Last

Are you here for yourself or a loved one?(Required)

Myself

Loved One

Do you/they suffer from any of these conditions?(Required)

How much of your time is spent worrying about your condition?(Required)

All the time

Most of the time

Sometimes

A little of the time

Not at all

Would you say this has effects on other people in your life or your relationship with them? (Select all that apply - hold ctrl to select more than one)(Required)

If you choose anyone other than yourself, does it concern you that it effects others?

yes

Have you sought help for your condition in the past?(Required)

Yes, it helped

Yes, it didn't help

No, but i want to

Whats your Email?(Required)

About Me

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Chronic pain
Stress & Anxiety
Grieving
Dyslexia
Cystic Fibrosis
Insomnia
Rheumatoid Arthritis
Speech impediment
Harmful Thoughts
Isolation & Loneliness
Strained Relationships
Addiction
Stuck
Non of the above

Just Me
My Partner
My Children
My Parents
Other Family Members
My Friends
My Work Colleagues
The General Public

Health Questionaire

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