New Patient Questionnaire

To be completed by all new patients. Your medical history, as described in this questionnaire, will form the basis of your assessment with DR Krishna It provides essential background information regarding your pain condition, and makes the consultation process more efficient.

Please ensure you fill in the required fields marked with an asterisk (*)
  • Date Format: MM slash DD slash YYYY
  • GP Details

  • Describe the pain

  • What treatments have you had and what was their outcome?

  • Other Information

  • Questions

  • Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your:

  • This field is for validation purposes and should be left unchanged.
Please note, all information given on this proforma remains confidential. Thank you for taking the time to complete this questionnaire.
Please note that the outcome will be based on the information you have provided. Therefore, Pain Spa Limited accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.