{"id":3355,"date":"2020-06-22T15:53:00","date_gmt":"2020-06-22T14:53:00","guid":{"rendered":"https:\/\/www.judybowenjonesacupuncture.co.uk\/?page_id=3355"},"modified":"2023-03-06T17:22:51","modified_gmt":"2023-03-06T17:22:51","slug":"new-patient-questionnaire","status":"publish","type":"page","link":"https:\/\/judybowenjonesacupuncture.co.uk\/new-patient-questionnaire\/","title":{"rendered":"New Patient Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3355\" class=\"elementor elementor-3355\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6120195 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6120195\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2d501d4\" data-id=\"2d501d4\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-bb1681e elementor-widget elementor-widget-heading\" data-id=\"bb1681e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">New Patient Questionnaire<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-675455e elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"675455e\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d5addc1 elementor-widget elementor-widget-breadcrumbs\" data-id=\"d5addc1\" data-element_type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<p id=\"breadcrumbs\"><span><span><a href=\"https:\/\/judybowenjonesacupuncture.co.uk\/\">Home<\/a><\/span><\/span><\/p>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-519718b1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"519718b1\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-141d9a59\" data-id=\"141d9a59\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-422b8b31 elementor-widget elementor-widget-text-editor\" data-id=\"422b8b31\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3354-o1\" lang=\"en\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/3355#wpcf7-f3354-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"3354\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3354-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:3354,&quot;conditions&quot;:[],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div id=\"two-column-contact\">\n\t<div class=\"left-column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient name*\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"right-column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date-of-birth\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of birth*\" value=\"\" type=\"text\" name=\"date-of-birth\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div id=\"main-contact\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" name=\"your-address\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<div id=\"two-column-contact\">\n\t<div class=\"left-column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gp-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"GP name*\" value=\"\" type=\"text\" name=\"gp-name\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gp-address\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"GP address\" name=\"gp-address\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"right-column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email address*\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Confirm your email address*\" value=\"\" type=\"email\" name=\"your-email2\" \/><\/span>\n\t\t<\/p>\n\t\t<p>PLEASE check the email address entered above is correct.\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobile-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Mobile number*\" value=\"\" type=\"text\" name=\"mobile-number\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"home-number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home telephone number*\" value=\"\" type=\"text\" name=\"home-number\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"main-contact\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-occupation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Occupation*\" value=\"\" type=\"text\" name=\"your-occupation\" \/><\/span><\/>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"appt-date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Provisional date of appointment (if known)\" value=\"\" type=\"text\" name=\"appt-date\" \/><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-prac\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Other practitioners used, e.g. physiotherapist, chiropractor\" name=\"other-prac\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<h3>Note from Judy Bowen-Jones:\n\t\t<\/h3>\n\t\t<p>Usually I would take full details of your current health issues and past medical history face to face, as part of your initial consultation. But because of Covid-19, we have been instructed to keep any close contact to a minimum. So, for the time being, I am asking clients to complete this online questionnaire and submit it in advance of their appointment. In this way, we can reserve face to face time for physical examination and treatment.\n\t\t<\/p>\n\t\t<p>On receipt of your completed questionnaire, I will call you briefly to discuss any questions.\n\t\t<\/p>\n\t\t<p>Before your appointment you will also be required to complete separate Covid-19 Screening and Consent Forms.\n\t\t<\/p>\n\t\t<h3>Main condition:\n\t\t<\/h3>\n\t\t<p>Please describe the main condition\/symptom you are seeking acupuncture for at the present time\n\t\t<\/p>\n\t\t<p><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-condtion\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please include details of the severity of your complaint, on a scale of 1-10, where 1 is mild and 10 very severe; approximately how long you have had it for; whether it\u2019s getting better or worse; what other treatment you have received; what is the nature of any pain (eg stabbing, burning); what makes it worse\/better. If you are a fertility or IVF patient, please provide details of your circumstances and dates for any planned IVF procedures.\" name=\"your-condtion\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Other conditions:\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-condtion\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please include details of any other conditons you are suffering from.\" name=\"other-condtion\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<h3>Past Medical History:\n\t\t<\/h3>\n\t\t<p><strong>Do you (does the patient, if you are completing for an under 16) currently suffer from, or have you ever suffered from any of the following conditions or illnesses:<\/strong>\n\t\t<\/p>\n\t\t<p>Heart problems\/endocarditis\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"heart\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"heart\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"heart\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Dizziness\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dizziness\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"dizziness\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"dizziness\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Epilepsy\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsy\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"epilepsy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"epilepsy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Blood\/bleeding disorders\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"blood-bleeding\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"blood-bleeding\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"blood-bleeding\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Diabetes\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"diabetes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"diabetes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Allergies\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"allergies\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"allergies\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>If you have answered yes to any of the questions above, please give details in the box below\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-details\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"history-details\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p><strong>Please indicate if you have had any of the following:<\/strong>\n\t\t<\/p>\n\t\t<p>Chicken Pox\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"chicken-pox\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"chicken-pox\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"chicken-pox\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Measles\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"measles\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"measles\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"measles\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Mumps\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mumps\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"mumps\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"mumps\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Glandular Fever\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"glandular-fever\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"glandular-fever\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"glandular-fever\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>If yes, at what age did you have Glandular Fever?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fever-age\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Age\" value=\"\" type=\"text\" name=\"fever-age\" \/><\/span>\n\t\t<\/p>\n\t\t<p>Infectious disease such as Hepatitis B or C, HIV, AIDS\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"infect-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"infect-disease\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"infect-disease\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>If yes, please give details here\n\t\t<\/p>\n\t\t<p><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"infect-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Details of infectious diseases\" name=\"infect-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p><strong>NB: All patients will also be required to complete a separate Covid-19 Screening Form<\/strong>\n\t\t<\/p>\n\t\t<p><strong>Please give brief details (including your approximate age at the time) of any illnesses, operations, accidents, broken bones, trauma, illness abroad, serious gastrointestinal upset, bad insect bites etc<\/strong>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-illness\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"e.g. Tonsils removed, age 7; Whiplash injury age 25; indigestion age 40, arthritis of the knee since age 50\" name=\"other-illness\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p><strong>Family History:<\/strong>\n\t\t<\/p>\n\t\t<p><strong>Does anyone in your immediate family (parents and siblings) suffer from:<\/strong>\n\t\t<\/p>\n\t\t<p>Asthma\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"asthma-family\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"asthma-family\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"asthma-family\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Eczema\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"eczema-family\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"eczema-family\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"eczema-family\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Thyroid problems\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"thyroid-problems-family\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"thyroid-problems-family\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"thyroid-problems-family\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Diabetes\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes-family\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"diabetes-family\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"diabetes-family\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Arthritis\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"arthritis-family\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"arthritis-family\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"arthritis-family\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Auto immune disease\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"auto-immune-disease-family\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"auto-immune-disease-family\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"auto-immune-disease-family\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><strong>Medication:<\/strong>\n\t\t<\/p>\n\t\t<p>Please give details of any medications or supplements you are taking:\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medication-box\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Include the name\/s of the medication\/s, how long you have been taking it for and the condition\/s being treated\" name=\"medication-box\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p><strong>General Information &#038; Test Results:<\/strong>\n\t\t<\/p>\n\t\t<p>Is your blood pressure: (please tick the one that best applies)\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"blood-pressure-level\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"blood-pressure-level\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"blood-pressure-level\" value=\"Low\" \/><span class=\"wpcf7-list-item-label\">Low<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"blood-pressure-level\" value=\"Borderline high\" \/><span class=\"wpcf7-list-item-label\">Borderline high<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"blood-pressure-level\" value=\"High\" \/><span class=\"wpcf7-list-item-label\">High<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"blood-pressure-level\" value=\"Controlled by medication\" \/><span class=\"wpcf7-list-item-label\">Controlled by medication<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"blood-pressure-level\" value=\"Don&#039;t know\" \/><span class=\"wpcf7-list-item-label\">Don&#039;t know<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Have you had any abnormal blood test results? eg for cholesterol, iron or have you ever been anaemic?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"blood-results\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"blood-results\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"blood-results\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>If yes, please give details\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"blood-details\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"blood-details\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>How would you best describe your energy levels?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"energy-levels\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"energy-levels\" value=\"Very good\" \/><span class=\"wpcf7-list-item-label\">Very good<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"energy-levels\" value=\"Ok\" \/><span class=\"wpcf7-list-item-label\">Ok<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"energy-levels\" value=\"Low\" \/><span class=\"wpcf7-list-item-label\">Low<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"energy-levels\" value=\"Variable\" \/><span class=\"wpcf7-list-item-label\">Variable<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>How would you describe your stress levels?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stress-levels\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"stress-levels\" value=\"High\" \/><span class=\"wpcf7-list-item-label\">High<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"stress-levels\" value=\"Manageable\" \/><span class=\"wpcf7-list-item-label\">Manageable<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"stress-levels\" value=\"Low\" \/><span class=\"wpcf7-list-item-label\">Low<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Do you get headaches or migraines?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"headaches\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"headaches\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"headaches\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>If Yes, give details\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"headache-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"e.g. migraines with nausea and aura since teens, tension headaches when I am tired\" name=\"headache-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Do you have any recurrent\/background health conditions eg skin problems, arthritis?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"background-conditions\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"background-conditions\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"background-conditions\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Please give details\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"background-conditions-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"background-conditions-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>How is your sleep?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sleep-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please give details\" name=\"sleep-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>What forms of exercise do you take, how often?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"excercise-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please give details\" name=\"excercise-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Please tell me a little about your appetite and diet.\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diet-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"e.g. Do you eat well, is there anything unusual about your diet? Are you vegan\/vegetarian? Do you eat late or skip meals? Do you eat your 5 a day? Do you avoid certain foods?\" name=\"diet-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Do you have any digestive problems eg heartburn, IBS, indigestion, bloating, constipation, loose bowels etc?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"digestive-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"digestive-problems\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"digestive-problems\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"digestive-problems-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"If Yes, please give details.\" name=\"digestive-problems-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Any past or current issues with your bladder\/ prostate or kidneys?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"bladder-problems\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"bladder-problems\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"bladder-problems\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bladder-problems-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"If Yes, please give details.\" name=\"bladder-problems-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Thirst &#8211; Do you tend to be:\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"thirst\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"thirst\" value=\"Very thirsty\" \/><span class=\"wpcf7-list-item-label\">Very thirsty<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"thirst\" value=\"Normally thirsty\" \/><span class=\"wpcf7-list-item-label\">Normally thirsty<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"thirst\" value=\"Not very thirsty\" \/><span class=\"wpcf7-list-item-label\">Not very thirsty<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>How much water do you drink a day?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"water-drunk\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"water-drunk\" \/><\/span>\n\t\t<\/p>\n\t\t<p>On average, how many caffeinated drinks do you consume per day?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"caffine-drunk\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caffine-drunk\" \/><\/span>\n\t\t<\/p>\n\t\t<p>How many carbonated drinks do you consume per day?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"carbonated-drunk\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"carbonated-drunk\" \/><\/span>\n\t\t<\/p>\n\t\t<p>How many units of alcohol do you consume per week?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol-drunk\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alcohol-drunk\" \/><\/span>\n\t\t<\/p>\n\t\t<p>Body temperature &#8211; Which of the following best applies to you:\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"body-temp\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"body-temp\" value=\"Generally normal\" \/><span class=\"wpcf7-list-item-label\">Generally normal<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"body-temp\" value=\"I tend to over-heat, I may go red or sweat easily\" \/><span class=\"wpcf7-list-item-label\">I tend to over-heat, I may go red or sweat easily<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"body-temp\" value=\"I feel the cold\" \/><span class=\"wpcf7-list-item-label\">I feel the cold<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"body-temp\" value=\"I get alternating hot and cold\" \/><span class=\"wpcf7-list-item-label\">I get alternating hot and cold<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"body-temp\" value=\"None of the above\" \/><span class=\"wpcf7-list-item-label\">None of the above<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>Does environmental temperature or the weather make your symptoms better or worse?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"environmental-symptoms\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"environmental-symptoms\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"environmental-symptoms\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"environmental-symptoms-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"If Yes, please give details.\" name=\"environmental-symptoms-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<h3>Women\u2019s Health &#038; Fertility\n\t\t<\/h3>\n\t\t<p>Are you menopausal?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"menopause\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"menopause\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"menopause\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><strong>If you are menopausal:<\/strong>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"periods-stop\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"What age did your periods stop?\" value=\"\" type=\"text\" name=\"periods-stop\" \/><\/span>\n\t\t<\/p>\n\t\t<p>Do you have any menopausal symptoms?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"menopause-symptoms\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"menopause-symptoms\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"menopause-symptoms\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menopause-detail-yes\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please give details of your menopausal symptoms\" name=\"menopause-detail-yes\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p><strong>If you are not menopausal:<\/strong>\n\t\t<\/p>\n\t\t<p>Tell me about your periods\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"period-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"e.g. are they regular\/ do you have period pain\/ pre-menstrual symptoms or other problems? Please give details\" name=\"period-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Do you have PCOS?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pcos-check\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"pcos-check\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"pcos-check\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"pcos-check\" value=\"Don&#039;t know\" \/><span class=\"wpcf7-list-item-label\">Don&#039;t know<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pcos-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please give details of your PCOS\" name=\"pcos-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Do you have endometriosis?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endometriosis-check\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"endometriosis-check\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"endometriosis-check\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"endometriosis-check\" value=\"Don&#039;t know\" \/><span class=\"wpcf7-list-item-label\">Don&#039;t know<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endometriosis-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please give details of your endometriosis\" name=\"endometriosis-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Please give details of your Contraceptive history\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contraception-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"contraception-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<h3>Pregnancy\n\t\t<\/h3>\n\t\t<p>Are you pregnant?\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant-check\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"pregnant-check\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"pregnant-check\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p>If you are pregnant, please give details\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"How many weeks? Is this your first baby? Do you have any complications? Have you had pregnancy complications in the past? When is your due date\" name=\"pregnant-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<p>Finally, anything else you would like to mention, that has not been covered already\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-detail\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"\" name=\"other-detail\"><\/textarea><\/span>\n\t\t<\/p>\n\t\t<h4>Sincere thanks for taking the time to complete this questionnaire. For your acupuncture treatment to be effective, it is important that I have as full a picture of you and your health as possible.\n\t\t<\/h4>\n\t\t<h4>Once I have received this, I will call you for a brief chat.\n\t\t<\/h4>\n\t\t<h4>I look forward to meeting you.\n\t\t<\/h4>\n\t\t<h4>Best wishes\n\t\t<\/h4>\n\t\t<h4>Judy Bowen-Jones\n\t\t<\/h4>\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"137\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>New Patient Questionnaire<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.6 - 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