PERSONAL INFORMATION SHEET

(CONSULTATION/APPOINTMENT/TREATMENT)

Please fill in the form on line and post. The Doctor will reply by E-Mail for action at your end.

Name 

Your Age Sex (M/F) 

Address 
                 
                 

Telephone No 

E-Mail 

Country 

Height (Feet/cms) 

Weight (Lbs/Kg.) 

Blood Group 

BLOOD PRESSURE

NORMAL
HIGH
LOW
 

PRESENT STATE OF HEALTH

EXCELLANT
VERY GOOD
GOOD
NOT GOOD
 

TREATMENT /CONSULTATION NEEDED FOR:

HEAD ACHE
ASTHMA
BACK PAIN
COLD/SINUS
ACIDITY
CONSTIPATION
HIGH BP
DIABETES
ARTHRITIS
SKIN ALLERGIES
General Fitness

Are you a member of Acupressure Club ? (Y/N)

YES
NO

Would you like to become a member of Acupressure Club ? (Y/N)

Yes
No

Additional Informations, if any