Client Intake form — Neulife Therapy

About You

First name *

Last name *

Date of birth *

Phone *

Address *

GP name

GP surgery

Emergency contact name *

Emergency contact phone *

Your Condition

What brings you to Neulife Therapy? *

When did this begin?

How did it start?

Symptoms are currently

Seen anyone for this before?

Symptoms

Do you experience dizziness or balance problems?

No Yes

Type of dizziness

Vertigo (spinning) Lightheadedness Imbalance Floating / rocking Visual disturbance on movement

Triggers

Head movement Position change Busy environments No clear trigger

Episode duration

Previous vestibular diagnosis

Medical Background

Existing neurological diagnosis

Past medical history

Current medications

Known allergies

Function & Goals

Mobility aids currently used

What are your main goals for physiotherapy? *

Consent & Declaration

Your information is held securely and processed in line with UK GDPR and the Data Protection Act 2018. It is used solely to support your care and will not be shared without your consent, except where required for essential clinical communication.

Date *

New Client Intake Form

Thank you

Tom@neulifetherapy.com