Health Review Questionnaire

First/Last Name(s) *

Date of Birth

Address

Mobile Telephone Number

Email Address *

Do you suffer from any existing medical conditions?

Are you currently on any medication?

Do you consent to us informing your GP, if felt appropriate in the event of any significant results or findings?

Yes (GP)
No (GP)

If yes, please complete the information below with your GP's details:

Name

Address

Telephone number

Email Address

We recognise that when you provide us with personal information you are trusting us to take good care of it. Please refer to our Privacy Policy for more information about how we collect, use, and protect your data.

Please tick the test(s) you’re booked in for

Iron Test (for tiredness)
Thyroid Test
Vitamin D Test

I consent to a blood sample being taken from my finger to see whether the test/s I have indicated above are positive or negative.

Signature *

Date *

IMPORTANT NOTE: Our tests are not a substitute for seeing your Doctor, especially if you are suffering symptoms. We will interpret your results based on National Guidelines. You will be advised to see your Doctor for any follow-up action.

‘Take control of your health today’

thehouseofwellbeing.co.uk

THE BRIDGE X THE LONDON HOUSE OF WELLBEING

‘Take control of your health today’