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Please fill in the form below with your personal details as well as your health information.

This will allow us to have some background on your condition, allowing us to

arrive at an appropriate initial clinical diagnosis.

                    Your Email Address:                    

                                 Full Name:                                  

       Company Name (If Applicable):     

                     Address:                      

 

Comments, details or questions?


                      

                    Appointment Date:                       

                      Appointment Time:                       

                         Telephone (WK):                          

                       Telephone (MB):                         

                         Telephone (Fax):                          

 

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Only complete below details for your first treatment (This is a one-off procedure upon initial consultation)

 

Have you had a treatment for you condition previously?

 


 

What is your choice of therapy

 

 

Are you currently taking medication?

 

Please list previous treatment for injury or any medication (if applicable)


 

Do you have any medical conditions presented below (Please tick box):

       Heart Disease

       Chest Pain

       High/Low Blood Pressure

       Pregnant

       Poor Circulation

       Varicose Veins

       Thrombosis/Clots

       Diabetes

       Epilepsy

Breathing difficulties

Asthma/Bronchitis

Dizziness

Nausea

Headaches

Migraines

Recent Infections

Bone Fractures

Liver Disease

Hepatitis

HIV/AIDS

Glandular Fever

Rheumatic Fever

Arthritis

Osteoporosis

Cancer

 

 

The Wellbeing Centre Specialises in: Acupuncture,Chinese Herbal Medicine,Chinese Massage (Tui Na),Remedial Massage,Reflexology,Dietary advice,Qi Gong,Tai Chi,Tai Chi Sword & Fan,Chinese Massage & cupressure classes,Herbal Beauty treatment in manly,dee why,freshwater,balgowlah,collaroy,narrabeen,manly vale,seaforth,curl curl,queenscliff, brookvale,narraweena,fairlight,mosman,beacon hill,allambie heights,cromer,elanora heights,warriewood,mona vale,warringah,cremorne,bilgola,avalon newport,palm beach,cammeray. Contact at Manly Clinic (Main Clinic) 3/37 Belgrave St,Manly 2095,Sydney,Ph: (02) 99778789,Mb: 0403014319.Seaforth Clinic,3/559 Sydney Rd,Seaforth 2092,Sydney,Ph: (02) 99778789,Mb: 0403014319.

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