0800 118 2892
Date of birth
Address Line 2
State / Province / Region
ZIP / Postal Code
Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions.
Have you ever suffered from heart or lung problems? YesNoX
Have you ever suffered from liver failure? YesNoX
Have you ever suffered from a head injury? YesNoX
Have you ever suffered from seizures or fits? YesNoX
Have you ever suffered from Asthma? YesNoX
Have you ever suffered from blood pressure problems? YesNoX
Have you ever suffered from balance problems? YesNoX
Have you ever suffered from Diabetes? YesNoX
Have you ever suffered from pancreas disorders? YesNoX
Have you ever had problems of swelling? (E.g. in the stomach or feet) YesNoX
Are you allergic to any medication? YesNoX
Have you ever suffered from any mental health problems? YesNoX
Have you ever been sectioned under the Mental Health Act? YesNoX
Have you ever attempted to harm yourself in any way, for example, taken any overdoses, cutting yourself etc.? YesNoX
Have you ever deliberately attempted to kill yourself? YesNoX
Are you suffering from any medical conditions at the moment? YesNoX
Are you currently taking any medication? YesNoX
Have you had a blood test in the last four weeks about which we may contact your doctor? YesNoX
Do you currently use any street drugs, for example, heroin, cocaine, cannabis etc.? YesNoX
Have you ever undertaken a "detox" for alcohol or drug problems in the past? YesNoX
Please provide the name, age and address of the adult who has agreed to supervise your medication, should you be issued with a prescription.
When did you last see your doctor? —Please choose an option—This WeekLast WeekThis MonthLast Month3-6 MonthNot recently
Are you currently being seen by someone from a community drug or alcohol service? YesNoX
Is the above information correct at the time of completing this assessment? Please confirm by printing your name which will constitute as a signature and check the box so that you have read our Service Agreement and that you agree to the terms and conditions it sets out
Please select either “Yes ” or “No” or “X” for “Don’t know”. Answer all questions.
How We Help Them
We know that it is vital to view our patients as individuals and to offer a safe and kind environment that helps to support their healing journey.
We provide a healthy environment uniquely suited to support your growth and healing.