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RETHINK YOUR HEALTH
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Home
About
About us
Contact Us
Payment Details
Commonly Asked Questions
Treatments
Consultations
Price List
Daily Schedule
What’s Included
New Start
More
Health Assessment Form
Donate
Share your story
Documents
Health Assessment Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Personal Details of Patient
Name
*
First
Last
Date of birth
*
Date of birth
Email
*
Phone
*
Gender
*
Male
Female
Home country
*
Physical address of residence
*
Current Citizenship
Marital Status
Home language
*
Other languages
Current employment
How many dependants do you have?
Do you have health insurance?
Yes
No
Details of your PARTNER or SPOUSE
Partner/Spouse Name
First
Last
Partner/Spouse Email
Partner/Spouse Phone
Partner/Spouse Gender
Male
Female
Background
How did you hear about Verity?
*
What is the main health problem that you are seeking help for from Verity Centre?
*
Give us as much info as you can
Medical & Surgical Conditions
Please list all medical and surgical CONDITIONS or symptoms which are a problem to you now. SINCE WHEN you have had it, WHEN it occurs, and what makes it BETTER or WORSE. If possible, you can tell us in which year each condition was diagnosed, and how the diagnosis was made (e.g. by a doctor, with a scan, etc.)."
Health condition
Information
Please complete all of the below information.
Height
cm
Weight
kg
Fitness level
Unfit
Getting started
Improving
Fit
Athlete
How far can you walk before becoming out of breath?
km
How far can you jog/run before becoming out of breath?
meters
Do you presently have any wounds?
Do you have any knee or foot injuries?
Do you need assistance with
Bathing
Toilet
Walking
Eating
Remedies
Please list all natural remedies and supplements/herbs you use, and indicate how frequently you use them:
Natural remedies and supplements
Treatment History
Medications
Write down all the MEDICATIONS you are taking NOW and include dosage and frequency. (Include birth control pills, pain medications, diet hormones, vitamins, minerals, and supplements.)
Submit