Initial Consultation - Daith Piercing 2020

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* 1. Please Fill In Your Details Below

First Name

Surname

Address

Address 2

City/Town

State/Province

Postal Code

Phone Number

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* 2. Email address

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* 3. Today's Date

Date / Time

Date

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* 4. What clinic is this today

Sussex - Burgess Hill

London - Harley Street

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* 5. Are you Male or Female

Male

Female

Trans Gender

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* 6. Your age Please

10/15

15/20

20/30

30/40

40/50

50/60

60/70

Over 70

Other (please specify)

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* 7. What do you do for a living / during the day

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* 8. What best describes your symptoms - tick appropriate

Migraine

Tension Headache

Cluster Headache

Head Fog

Constant Head Fog

Anxiety

Hyper Vigilance

Post Traumatic Stress Disorder PTSD

Obsessive-Compulsive Disorder OCD

Depression

Silent Migraine

Stomach Migraine

Irritable Bowel Syndrome IBS

Fibromyalgia only

Swallowing Disorder

Other (please specify)

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* 9. How was the initial stimulation test

Very Positive on Left & Right

Somewhat Positive on Left & Right

Not positive on Left & Right

Left only - Very Positive

Left only - Somewhat Positive

Right only - Very Positive

Right only - Somewhat Positive

No Reaction

Negative Left

Negative Right

Other (please specify)

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* 10. Is this consultation Migraine / Headache related

Yes