Patient Registration Leave this field blank Personal Information Mr Mrs Ms Miss Date of Birth (optional) Medical Checklist Have you had any operations, if yes please give details: (optional) Have you had any of the following? Please tick (optional) Severe Headaches Heart Condition Epilepsy Cancer Car Accident Other Accident Skin Conditions Do you Smoke? Bladder Problem Spinal Fractures Osteoporosis Gynaecological Conditions Pacemaker An aneurysm Strokes / Blood clots Osteoarthritis (joint “wear and tear”) Dislocations Rheumatoid arthritis Ligament injuries Ankylosing spondylitis Cartilage injuries Psoriatic arthritis Lung problems Others Are currently seeing a doctor on any conditions? (optional) If you are taking any medication(s) please list (optional) Do you have any injury, if yes, please give details (optional) Send
