New Patient Form | BodyEase Osteopathy Twickenham

Your details

So we can reach you and keep accurate records.

Full name *

Date of birth *

Phone number *

Email address *

Address

Emergency contact name

Emergency contact phone

GP name

GP practice

Only needed if we ever need to communicate with your GP about your care.

How did you hear about us?

Your presenting complaint

What's brought you in.

Main reason for your visit *

When did it start?

How did it start?

Describe your pain or discomfort in your own words *

What makes it better?

What makes it worse?

Is this a new problem, or has it happened before?

Safety screening

This helps us make sure hands-on treatment is the right first step for you.

In the last few weeks, have you noticed any of these? Tick any that apply.

Numbness around the saddle or genital area, or new trouble controlling your bladder or bowel
Unexplained weight loss, fevers, or night sweats
A history of cancer with new, unexplained pain
A significant recent injury (fall, accident, or direct blow)
Worsening weakness, or pins and needles in both arms or both legs
Constant pain that does not ease with rest or position, especially at night

Medical history

This affects what's safe and appropriate to do in your assessment.

Current medications *

Allergies

Have you had any surgeries? If so, what and when? *

Existing diagnosed conditions (e.g. diabetes, osteoporosis, cardiovascular disease, blood clotting disorders or anticoagulant use)

Are you currently pregnant? *

Asked of every patient, as it can affect treatment technique and positioning.

Previous osteopathy or manual therapy? What worked, or didn't?

Lifestyle and daily function

Helps put your symptoms in context.

Occupation

General activity or exercise level

Sleep quality

How is this affecting your daily life or work?

Consent

Please read and confirm each of these.

Nothing is shared outside BodyEase. You can ask to see or remove your information at any time.