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Dermatologist >

Physiotherapist >

Acupuncturist >

Support us in finding
your ideal Chiropractor

A little about...

Please complete this questionnaire by providing some simple background information and the problems the patient would like to address in treatment. It will enable us to match the patient with a suitable Chiropractor. Your responses will also provide the Chiropractor with a solid foundation for getting to know the patient and the treatment required.

Chiropractor

Who is the appointment for?

Patient Information *

Myself

My child (under 18 yrs)

A friend or relative

Section Buttons

Next

Patient Complaint/Symptoms

What brings you to seek chiropractic care? *

Please describe your primary complaint or symptom. *

Back pain

Neck pain

Headaches

OtherOther

How long have you been experiencing this issue? *

Less than 1 week

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

Over 1 year

10 Being worse. What's the pain severity on a scale of 1-10?

Is the pain: *

Constant

A dull ache

It comes and goes

What triggers or worsens the pain? *

Does anything relieve the pain? *

Have you previously received chiropractic care for this issue? *

Yes

No

Section Buttons

Next

Injury/Accident History

Have you had any recent injuries or accidents? *

Yes

No

If yes please provide details.

Have you experienced similar symptoms in the past? *

Yes

No

If yes please provide details.

Have you undergone any previous treatments for this condition? (e.g., physiotherapy, massage therapy, medications) *

Yes

No

If yes please provide details.

Section Buttons

Next

Medical History

Do you have any other pre-existing medical conditions or chronic illnesses? (e.g., arthritis, osteoporosis) *

Yes

No

If yes please provide details.

Are you currently taking any medications? (Prescription or over-the-counter) *

Yes

No

If yes please provide details.

Do you have any allergies? *

Yes

No

If yes please provide details.

Have you had any surgeries, especially related to the spine, joints, or bones? *

Yes

No

If yes please provide details.

Section Buttons

Next

Lifestyle Questions

What is your level of physical activity? *

Sedentary (Low)

Moderate

Active (High)

Do you have any regular exercise or stretching routines? *

Yes

No

If yes please provide details.

What are your typical daily activities? *

Sitting

Standing

Lifting

Computer work

OtherOther

Do you experience stress, and does it affect your body? *

Yes

No

If yes please provide details.

Section Buttons

Next

Expectations and Goals

What are your goals or expectations from chiropractic care? *

Section Buttons

Is there anything specific you would like to discuss during your consultation? *

Next

Basic Information

Your name *

Your name

First

First

Last

Last

Your phone no *

Your Email

Your child's name

Your child's name

First

First

Last

Last

Your child's age

Your friend - relatives name

Your friend - relatives name

First

First

Last

Last

Your friend - relative's age

Occupation (to understand physical strain from work) *

Section Buttons

If you are human, leave this field blank.

Support us in finding
your ideal Chiropodist

A little about...

Please complete this questionnaire by providing some simple background information and the problems the patient would like to address in treatment. It will enable us to match the patient with a suitable Chiropodist. Your responses will also provide the Chiropodist with a solid foundation for getting to know the patient and the treatment required.

Chiropodist

Who is the appointment for?

Patient Information *

Myself

My child (under 18 yrs)

A friend or relative

Section Buttons

Next

Patient Complaint/Symptoms

What brings you to seek podiatry care? *

What specific areas of your foot or ankle are affected? *

Toes

Heel

Arch

Ankle

Entire foot

Have you noticed any deformities or changes in the appearance of your foot or ankle?

Bumps (e.g., bunions, cysts)

Overlapping toes

Flat feet or high arches

Toenail issues (e.g., ingrown toenails, thickened or discoloured nails)

OtherOther

How long have you been experiencing this issue? *

Less than 1 week

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

Over 1 year

10 Being worse. What's the pain severity on a scale of 1-10?

What type of symptoms are you experiencing? *

Pain (sharp, dull, throbbing)

Numbness or tingling

Swelling or inflammation

Redness or irritation

Stiffness or reduced mobility

Cuts, wounds, or ulcers

Changes in skin or nail colour/texture

Blisters or rashes

Is the pain or discomfort localized or does it spread to other areas (e.g., leg, calf)? *

What triggers or worsens your symptoms?

Walking or running

Standing for long periods

Wearing certain types of shoes

Cold or warm weather

Rest or inactivity

Specific movements or positions

OtherOther

Have you noticed any changes in your gait (the way you walk)? *

Limping

Dragging your foot

Shuffling

OtherOther

Section Buttons

Patient Complaint/Symptoms 2

Have you developed any wounds or ulcers on your feet? *

Yes

No

Are they

Healing

Getting worse

Staying the same

Are they

Painful

Painless

Do you experience pain or discomfort at a specific time of day?

No

Morning stiffness

Pain that worsens as the day progresses

Pain that is more noticeable at night or while resting

OtherOther

Does the pain or discomfort interfere with your daily activities or sleep? *

Does anything relieve the pain? *

Have you previously received chiropody/podiatry care for this issue? *

Yes

No

Section Buttons

Next

Injury/Accident History

Have you experienced any recent trauma or injury to your foot or ankle? *

Sprains

Falls

Accidents or heavy impact

Sports injuries

OtherOther

Have you experienced similar symptoms in the past? *

Yes

No

If yes please provide details.

Have you undergone any previous treatments for this condition? (e.g., Over the counter medications) *

Yes

No

If yes please provide details.

Section Buttons

Next

Medical History

Do you have any other pre-existing medical conditions or chronic illnesses? (e.g., arthritis, osteoporosis) *

Yes

No

If yes please provide details.

Are you currently taking any medications? (Prescription or over-the-counter) *

Yes

No

If yes please provide details.

Do you have any allergies? *

Yes

No

If yes please provide details.

Do you experience difficulty walking or standing for extended periods? *

Yes

No

If yes please provide details.

Section Buttons

Next

Lifestyle Questions

What is your level of physical activity? *

Sedentary (Low)

Moderate

Active (High)

Do you have any regular exercise or stretching routines? *

Yes

No

If yes please provide details.

What are your typical daily activities? *

Sitting

Standing

Lifting

Computer work

OtherOther

Do you experience difficulty walking or standing for extended periods? *

Yes

No

If yes please provide details.

Do you have any mobility aids *

No

Cane

Orthotic inserts

Wheelchair

OtherOther

Section Buttons

Next

Expectations and Goals

What are your goals or expectations from chiropodist care? *

Section Buttons

Is there anything specific you would like to discuss during your consultation? *

Next

Basic Information

Your name *

Your name

First

First

Last

Last

Your phone no *

Your Email

Your child's name

Your child's name

First

First

Last

Last

Your child's age

Your friend - relatives name

Your friend - relatives name

First

First

Last

Last

Your friend - relative's age

Occupation (to understand physical strain from work) *

Section Buttons

If you are human, leave this field blank.

Physiotherapist

Select your license type *

Bachelor of Physiotherapy (BPT)

Master of Physiotherapy (MPT)

Physiotherapy postgraduate (PG) diploma

OtherOther

Next

Where do you currently spend most of your time? *

Other online platforms like Pure

Clinic or hospital

Private practice

Community physiotherapy agency

Teaching or counselling in an academic setting

Other clinical setting

Not currently practicing

Next

How much of your time is currently spent on administrative and/or billing related tasks? *

Up to 10% of my time

10 to 30% of my time

More than 30% of my time

Next

What makes you most interested in Pure Medical? *

To build my own private practice

To supplement my private practice

To supplement my full-time job

Other

Next

How much time do you intend to spend with Pure Medical clients? *

Up to 5 hours a week

5 to 10 hours a week

10 to 20 hours a week

20 to 30 hours a week

More than 30 hours a week

Not sure

Next

How did you hear about Pure Medical?

Other

Email Outreach

Internet Research

Friend or colleague

Mail

Podcast

Next

Finally, please provide your contact information.

Name

Name

First

First

Last

Last

Section Buttons

Email

If you are human, leave this field blank.

MAKE AN ENQUIRY

A little about you...

Please complete this questionnaire by providing some simple background information about you and the problems you’d like to address in treatment. It will enable us to begin to build your treatment plan. Your responses will also provide our doctors with a solid foundation for getting to know you and the treatment you require.

Name *

Name

First

First

Last

Last

Email *

Phone *

Next

I am interested in treatment for: *

Arthritis

Dementia

Fibromyalgia

Long Covid

Stroke Recovery

Traumatic Brain Injury

PTSD

OtherOther

Next

How should we contact you? *

Call me

Send an email

If you are human, leave this field blank.

MAKE AN ENQUIRY

A little about you...

Please complete this questionnaire by providing some simple background information about you and the problems you’d like to address in treatment. It will enable us to begin to build your treatment plan. Your responses will also provide our doctors with a solid foundation for getting to know you and the treatment you require.

Who is the enquiry for? *

Myself

A relative

My child

A friend

Your relative's name

Your child's name

Your friend's name

Next

What type of Arthritis are you suffering from? *

Rheumatoid arthritis

Osteoarthritis

Gout

Psoriatic arthritis

Fibromyalgia

Lupus

Raynaud’s

Scleroderma

OtherOther

Next

What is your gender? *

Woman

Man

OtherOther

What are your pronouns? * What are your pronouns?

Next

Select your age range *

19 - 29

30 - 39

40 - 49

50 -59

60 - 69

70+

Next

What symptoms are you experiencing? *

Muscle & Joint Pain (MSK)

Muscle Stiffness

Brain Fog - Cognitive issues

Fatigue

Headaches

IBS

Frustration, anger, anxiety, or depression

Sleeping issues

OtherOther

Next

Where or how did the condition begin, has it developed, i.e. spread, is it localised or referred pain? * *

Next

Have you seen your GP? *

Have you had any tests carried out? *

Next

Have you previously had treatment for this condition? *

Yes

No

Next

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Next

How would you describe the pain? *

Burning

Aching

Stabbing

OtherOther

Next

Are you experiencing any of the following conditions? *

None

Prickling

Tingling

Knife-like

Electric Shock

Squeezing

Constricting

Hurting

Burning

Freezing

Throbbing

Allodynia

Hyperalgesia

Next

What makes the pain worse? *

What makes the pain better? *

Is the pain worse at certain times of the day? *

Next

Are you experiencing any of these issues? *

Experience dizziness

Slurred speech

Trouble swallowing

Blurred vision

Feeling faint

Numbness

Black spots in the eyes

Nausea

None

Next

Are you experiencing any of the following? *

Bladder or bowel disfunction

Option Saddle anaesthesia - Reduced sensation in the perineum, buttocks, anus, groin and upper thighs

Gait issues

Sexual dysfunction

None

Next

Have you experienced any? *

Unexplained weight loss

Night sweats or fever

Unrelenting pain

Generally feeling unwell

None

Next

Do your joints? *

Click

Lock

Give way

Are they red or bruised

Do you suffer from swelling and inflammation

None

Next

Do you suffer from?

Morning stiffness

Small joint swelling

IBS

Are you worse with rest

None of the above

Next

Please provide a brief outline of your medication history? *

Next

Social history - What job do you do? Any sports/hobbies? Family set up? *

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke *

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Your Name *

Your Name

First

First

Last

Last

Email

Phone

If you are human, leave this field blank.

Support us in understanding
your condition

A little about you...

Please complete this questionnaire by providing some simple background information about you and the problems you’d like to address in treatment. It will enable us to understand and treat your condition. Your responses will also provide us with a solid foundation for getting to know you and the treatment you require.

What is your gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are your pronouns? *

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What condition are you suffering from? *

Dementia

Post-Concussion Syndrome

Long COVID Symptoms

Post Stroke Recovery

Fibromyalgia

Lyme Disease

Frustration, anger, anxiety, or depression

Sleeping Issues

Post Traumatic Stress Disorder PTSD

OtherOther

Next

How and when did the symptoms start? *

Next

Have you seen your GP regarding your condition? *

Have you had any tests carried out?

Next

Have you had treatment for your condition before? *

Yes

No

Next

On a scale of 1 - 10, Are you suffering from pain? (0 being no pain - 10 being excruciating pain) *

Next

Is your sleep affected by your condition? *

Next

Are you experiencing any of these issues? *

Experience dizziness

Slurred speech

Trouble swallowing

Blurred vision

Feeling faint

Numbness

Black spots in the eyes

Nausea

None

Next

Are you experiencing any of the following?

Bladder or bowel disfunction

Saddle anaesthesia - Reduced sensation in the perineum, buttocks, anus, groin and upper thighs

Gait issues

Sexual dysfunction

None

Next

Have you experienced any:

Unexplained weight loss

Night sweats or fever

Unrelenting pain

Generally feeling unwell

None

Next

Do your joints: *

Click?

Lock?

Give way?

Are they red or bruised?

Do you suffer from swelling and inflammation?

None

Next

Do you suffer from:

Morning stiffness?

Small joint swelling?

IBS?

Are you worse with rest?

Next

Medical History, have you suffered any problems with your:

Thyroid issues

Heart/Cardiovascular issues

Rheumatoid arthritis? (In family)

Epilepsy

Asthma/Respiratory conditions

Diabetes

Steroid medication

Osteoporosis

Previous history of cancer

Previous operations or injuries on the same body part

Next

Please provide medication history *

Next

Social history - What job do you do? Any sports/hobbies? Family set up?

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke? *

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

If you are human, leave this field blank.

Please provide some details

A little about you and your practice...

Please complete this questionnaire by providing some simple background information about you and your healthcare practice. It will enable us to carryout a high-level review of your company.

Sell Your Practice

What type of practice are you selling? *

Dentist

Doctor

Physiotherapy

Counselling

Chiropody/Podiatry

Chiropractor

Dermatologist

OtherOther

Next

Reason for Sale *

Retirement

To concentrate on other projects

OtherOther

Next

Type of Company *

Limited Company

Sole Trader

Limited Liability Partnership (LLP)

OtherOther

Next

Company Name *

Company Address *

Next

Do you hold financial records for the last five years? *

Yes

No

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

If you are human, leave this field blank.

Podiatrists

Select your license type *

IOCP (Institute of Chiropodists and Podiatrists Registered)

BCPA (British Chiropody and Podiatry Association Registered)

The Society of Chiropodists and Podiatrists (HCPC Registered)

The Alliance of Private Sector Practitioners

OtherOther

Next

Where do you currently spend most of your time? *

Clinic or hospital

Private practice

Community health agency

Teaching in an academic setting

Other clinical setting

Not currently practicing

Next

How much of your time is currently spent on administrative and/or billing related tasks? *

Up to 10% of my time

10 to 30% of my time

More than 30% of my time

Next

What makes you most interested in Pure Medical? *

To build my own private practice

To supplement my private practice

To supplement my full-time job

Other

Next

How much time do you intend to spend with Pure Medical clients? *

Up to 5 hours a week

5 to 10 hours a week

10 to 20 hours a week

20 to 30 hours a week

More than 30 hours a week

Not sure

Next

How did you hear about Pure Medical?

Other

Email Outreach

Internet Research

Friend or colleague

Mail

Podcast

Next

Finally, please provide your contact information.

Name

Name

First

First

Last

Last

Section Buttons

Email

Phone

If you are human, leave this field blank.

Support us in finding
the ideal Acupuncturist

A little about your child...

Please complete this questionnaire by providing some simple background information about your child and the problems they’d like to address in treatment. It will enable us to match you with a suitable acupuncturist. Your responses will also give the acupuncturist a solid foundation for getting to know your child and the treatment they require.

Child's gender? *

Boy

Girl

Next

Select their age range *

Under 3 years old

3-6 years old

6-10 years old

10-12 years old

12-15 years old

Over 15 years old

Next

What do they require acupuncture for? *

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Are there any specific preferences for the doctor? *

Male doctor

Female doctor

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
the ideal Acupuncturist

A little about your friend / relative...

Please complete this questionnaire by providing some simple background information about your friend/relative and the problems they’d like to address in treatment. It will enable us to match you with a suitable acupuncturist. Your responses will also give the acupuncturist a solid foundation for getting to know your friend/relative and the treatment they require.

Friend / relatives gender? *

Woman

Man

Prefer not to say

What are their pronouns?

Next

Select their age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What do they require acupuncture for? *

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Do they smoke?

Yes

No

Next

How often do they drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for the doctor? *

Male doctor

Female doctor

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
your ideal acupuncturist

A little about you...

Please complete this questionnaire by providing some simple background information about you and the problems you’d like to address in treatment. It will enable us to match you with a suitable acupuncturist. Your responses will also provide the acupuncturist with a solid foundation for getting to know you and the treatment you require.

What is your gender? *

Woman

Man

Prefer not to say

What are your pronouns?

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What do you require acupuncture for? *

Next

Please provide medication history *

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke?

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for your acupuncturist? *

Male acupuncturist

Female acupuncturist

No preference

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

Address *

If you are human, leave this field blank.

Support us in finding
the ideal Chiropodist

A little about your child...

Please complete this questionnaire by providing some simple background information about your child and the problems they’d like to address in treatment. It will enable us to match you with a suitable chiropodist. Your responses will also give the chiropodist a solid foundation for getting to know your child and the treatment they require.

Child's gender? *

Boy

Girl

Next

Select their age range *

Under 3 years old

3-6 years old

6-10 years old

10-12 years old

12-15 years old

Over 15 years old

Next

What Chiropodist service is required? *

Foot Pain Treatment

Callus (hard skin)

Corns

Dry cracked heels

In-growing toenails

Tough thickened nails

Verrucae

Not sure, need advice

OtherOther

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Are there any specific preferences for the chiropodist? *

Male chiropodist

Female chiropodist

No preference

Next

Do you require: *

A Chiropodist to visit you at home?

You visit a clinic?

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
the ideal Chiropodist

A little about your friend / relative...

Please complete this questionnaire by providing some simple background information about your friend/relative and the problems they’d like to address in treatment. It will enable us to match you with a suitable chiropodist. Your responses will also give the chiropodist a solid foundation for getting to know your friend/relative and the treatment they require.

Friend / relatives gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are their pronouns?

Next

Select their age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What chiropodist service is required? *

Foot Pain

Callus (hard skin)

Corns

Dry cracked heels

In-growing toenails

Tough thickened nails

Verrucae

Not sure, need advice

OtherOther

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Do they smoke?

Yes

No

Next

How often do they drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for the chiropodist? *

Male chiropodist

Female chiropodist

No preference

Next

Do you require: *

A Chiropodist to visit you at home?

You visit a clinic?

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
your ideal Chiropodist

A little about you...

Please complete this questionnaire by providing some simple background information about you and the problems you’d like to address in treatment. It will enable us to match you with a suitable Chiropodist. Your responses will also provide the Chiropodist with a solid foundation for getting to know you and the treatment you require.

What is your gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are your pronouns?

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What chiropodist service are you looking for? *

Foot Pain

Callus (hard skin)

Corns

Dry cracked heels

In-growing toenails

Tough thickened nails

Verrucae

Not sure, need advice

OtherOther

Next

Please provide medication history *

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke?

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for your chiropodist? *

Male chiropodist

Female chiropodist

No preference

Next

Do you require: *

A Chiropodist to visit you at home?

You visit a clinic?

No preference

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

Address *

If you are human, leave this field blank.

Support us in finding
the ideal Doctor

A little about your child...

Please complete this questionnaire by providing some simple background information about your child and the problems they’d like to address in treatment. It will enable us to match you with a suitable doctor. Your responses will also give the doctor a solid foundation for getting to know your child and the treatment they require.

Child's gender? *

Boy

Girl

Next

Select their age range *

Under 3 years old

3-6 years old

6-10 years old

10-12 years old

12-15 years old

Over 15 years old

Next

What doctors service do they require? *

Next

How and when did the pain start? Was there a specific injury? *

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Does the pain affect your sleep? *

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Are there any specific preferences for the doctor? *

Male doctor

Female doctor

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
the ideal Doctor

A little about your friend / relative...

Please complete this questionnaire by providing some simple background information about your friend/relative and the problems they’d like to address in treatment. It will enable us to match you with a suitable doctor. Your responses will also give the doctor a solid foundation for getting to know your friend/relative and the treatment they require.

Friend / relatives gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are their pronouns?

Next

Select their age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What Doctor service do they require? *

Next

How and when did the pain start? Was there a specific injury? *

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Does the pain affect your sleep? *

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Do they smoke?

Yes

No

Next

How often do they drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for the doctor? *

Male doctor

Female doctor

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
your ideal Doctor

A little about you...

Please complete this questionnaire by providing some simple background information about you and the problems you’d like to address in treatment. It will enable us to match you with a suitable doctor. Your responses will also provide the doctor with a solid foundation for getting to know you and the treatment you require.

What is your gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are your pronouns?

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What Doctor service do you require? *

Next

How and when did the pain start? Was there a specific injury? *

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Does the pain affect your sleep? *

Next

Please provide medication history *

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke?

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for your doctor? *

Male doctor

Female doctor

No preference

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

Address *

If you are human, leave this field blank.

Support us in finding
the ideal Dentist

A little about your child...

Please complete this questionnaire by providing some simple background information about your child and the problems they’d like to address in treatment. It will enable us to match you with a suitable dentist. Your responses will also give the dentist a solid foundation for getting to know your child and the treatment they require.

Child's gender? *

Boy

Girl

Next

Select their age range *

Under 3 years old

3-6 years old

6-10 years old

10-12 years old

12-15 years old

Over 15 years old

Next

What dental service is required? *

Emergency Dental Treatment

Fillings, Crowns, Veneers

Root Canal

Dentures

Dental Bridges

Tooth Removal

Oral Surgery

Gum Disease

Facial Aesthetics

Not sure, need advice

OtherOther

Next

How and when did the pain start? Was there a specific injury? *

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Does the pain affect your sleep? *

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Are there any specific preferences for the dentist? *

Male dentist

Female dentist

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
the ideal Dentist

A little about your friend / relative...

Please complete this questionnaire by providing some simple background information about your friend/relative and the problems they’d like to address in treatment. It will enable us to match you with a suitable dentist. Your responses will also give the dentist a solid foundation for getting to know your friend/relative and the treatment they require.

Friend / relatives gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are their pronouns?

Next

Select their age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What dental service is required? *

Emergency Dental Treatment

Fillings, Crowns, Veneers

Root Canal

Dentures

Dental Bridges

Tooth Removal

Oral Surgery

Gum Disease

Facial Aesthetics

Not sure, need advice

OtherOther

Next

How and when did the pain start? Was there a specific injury? *

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Does the pain affect your sleep? *

Next

Please provide medication history *

Next

How would you rate their current physical health? *

Good

Fair

Poor

Next

Do they smoke?

Yes

No

Next

How often do they drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for the dentist? *

Male dentist

Female dentist

No preference

Next

Your name *

Your name

First

First

Last

Last

Your email *

Your phone *

The patients name

The patients name

First

First

Last

Last

The patients address *

If you are human, leave this field blank.

Support us in finding
your ideal Dentist

A little about you...

By providing some simple background information about you and the problems you’d like to address in treatment, kindly complete this questionnaire. It will enable us to match you with a suitable dentist. Your responses will also provide the dentist with a solid foundation for getting to know you and the treatment you require.

Dentist Myself

What is your gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are your pronouns?

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What dental service are you looking for? *

Emergency Dental Treatment

Fillings, Crowns, Veneers

Root Canal

Dentures

Dental Bridges

Tooth Removal

Oral Surgery

Gum Disease

Facial Aesthetics

Not sure, need advice

OtherOther

Next

How and when did the pain start? Was there a specific injury? *

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Does the pain affect your sleep? *

Next

Please provide medication history *

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke?

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Are there any specific preferences for your dentist? *

Male dentist

Female dentist

No preference

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

Address *

If you are human, leave this field blank.

Fibromyalgia Support

A little about you...

By providing some simple background information about you and the fibromyalgia symptoms you’d like to address in treatment, kindly complete this questionnaire. Your responses will provide us with a solid foundation for getting to know you.

What is your gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

What are your pronouns? *

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

What fibromyalgia symptoms are you experiencing? *

Muscle & Joint Pain (MSK)

Muscle Stiffness

Fibro-fog - Cognitive issues

Fatigue

Headaches

IBS

Frustration, anger, anxiety, or depression

Sleeping Issues

Other

Other *

Next

How and when did the symptoms start? *

Next

Have you seen your GP for fibromyalgia? *

Have you had any tests carried out?

Next

Have you had fibromyalgia treatment before? *

Yes

No

Next

Where or how did the fibromyalgia start, has it developed, i.e. spread, is it localised or referred pain? *

Next

On a scale of 1 - 10, what is your pain level? (1 being low pain - 10 being excruciating pain) *

Next

How would you describe the pain?

Other- Please describe your symptoms

Next

Are you experiencing any of the following conditions? *

None

Prickling

Tingling

Knife-like

Electric shock-like

Squeezing

Constricting

Hurting

Burning

Freezing

Throbbing

Allodynia

Hyperalgesia

Next

What makes the pain worse? *

What makes the pain better? *

Is the pain worse at certain times of the day? *

Next

Does the pain affect your sleep? *

Next

Are you experiencing any of these issues? *

Experience dizziness

Slurred speech

Trouble swallowing

Blurred vision

Feeling faint

Numbness

Black spots in the eyes

Nausea

None

Next

Are you experiencing any of the following?

Bladder or bowel disfunction

Saddle anaesthesia - Reduced sensation in the perineum, buttocks, anus, groin and upper thighs

Gait issues

Sexual dysfunction

None

Next

Have you experienced any:

Unexplained weight loss

Night sweats or fever

Unrelenting pain

Generally feeling unwell

None

Next

Do your joints: *

Click?

Lock?

Give way?

Are they red or bruised?

Do you suffer from swelling and inflammation?

None

Next

Do you suffer from:

Morning stiffness?

Small joint swelling?

IBS?

Are you worse with rest?

Next

Medical History, have you suffered any problems with your:

Thyroid issues

Heart/Cardiovascular issues

Rheumatoid arthritis? (In family)

Epilepsy

Asthma/Respiratory conditions

Diabetes

Steroid medication

Osteoporosis

Previous history of cancer

Previous operations or injuries on the same body part

Next

Please provide medication history *

Next

Social history - What job do you do? Any sports/hobbies? Family set up?

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

Do you smoke? *

Yes

No

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

Name *

Name

First

First

Last

Last

Email *

Phone *

If you are human, leave this field blank.

Support us in finding
your ideal therapist

A little about you...

By providing some simple background information about you and the problems you’d like to address in treatment, kindly complete this questionnaire. It will enable us to match you with a suitable therapist. Your responses will also provide the therapist with a solid foundation for getting to know you.

What is your gender? *

Woman

Man

Non Binary

Transfeminine

Transmasculine

Agender

I don't know

Prefer not to say

Other

Other

Next

Select your age range *

13 - 19

20 - 24

25 -29

30 - 34

35 -39

40 - 44

45 -49

50 - 54

55 -59

60 - 64

65+

Next

How do you identify? *

Other

Would you like to be matched with a specialised LGBTQ+ therapist?

Yes

No

Next

Do you consider yourself religious? *

No

Yes

which religion do you identify with?

Christianity

Judaism

Islam

Other

Other

Next

What are your pronouns? *

Other

Next

What is your relationship status *

Other

Next

Do you consider yourself to be spiritual? *

No

Yes

Next

Have you ever been in therapy before? *

No

Yes

Next

What has led you to consider therapy now? *

I have been feeling depressed

I feel anxious or overwhelmed

My mood is interfering with my Job / School

I struggle with building or maintaining relationships

I can't find purpose or meaning in life

I am grieving

I have experienced trauma

I need to talk through a specific challenge

I want to gain self confidence

I want to improve myself but I am not sure where to start

Recommended to me (friend, family, doctor)

Just exploring

OtherOther

Next

What are your expectations from your therapist? A therapist who... *

Listens

Explores my past

Teaches me new skills

Challenges my beliefs

Assigns me homework

Guides me to set goals

Proactively checks in with me

Other

I don't know

Next

How would you rate your current physical health? *

Good

Fair

Poor

Next

How would you rate your current eating habits? *

Good

Fair

Poor

Next

Are you experiencing overwhelming sadness, grief, or depression? *

No

Yes

Next

In the last two weeks, have you had little interest or pleasure in doing things? *

Next

In the last two weeks, moving or speaking so slowly that others could notice, or the opposite, being fidgety or restless *

Next

In the last two weeks, trouble falling asleep, staying asleep, or sleeping too much *

Next

In the last two weeks, feeling depressed, down or hopeless *

Next

In the last two weeks, feeling tired or having little energy *

Next

In the last two weeks, poor appetite or overeating *

Next

In the last two weeks, feeling bad about yourself, or that you are a failure or let your family down. *

Next

In the last two weeks, trouble concentrating on things, such as reading or watching TV. *

Next

In the last two weeks, thought that you would be better off dead or of hurting yourself in some way. *

Next

In the last two weeks, how difficult have these problems made it for you to work, take care of things at home, or get along with other people? *

Next

Are you currently employed? *

No

Yes

Next

Do you have problems or worries about intimacy? *

No

Yes

Next

How often do you drink alcohol? *

Never

Infrequently

Monthly

Weekly

Daily

Next

When was the last time you thought about suicide? *

Never

Over a year ago

Over 3 months ago

Over a month ago

Over two weeks ago

In the last two weeks

Next

Are you currently experiencing anxiety, panic attacks or phobias? *

No

Yes

Next

Are you currently taking any medication? *

No

Yes

Next

Are you currently experiencing any chronic pain? *

No

Yes

Next

How would you rate your current financial status? *

Good

Fair

Poor

Next

How would you rate your current sleeping habits? *

Good

Fair

Poor

Next

How would you prefer to communicate with your therapist? *

Mostly via Messaging

Mostly via phone or video sessions

Not sure yet (decide later)

Next

Are there any specific preferences for your therapist? *

Male therapist

Female therapist

Christian-based therapist

LGBTQ+ therapist

Older therapist 45+

non-religious therapist

Therapist of ColourTherapist of Colour

Next

What is your preferred language? *

Preferred Language

Next

Please mark all that apply

I'm a student

I'm a veteran

I'm disabled

I'm unemployed

I'm employed but my income is low

I'm financially impacted by the coronavirus outbreak

Next

Name *

Name

First

First

Last

Last

Email *

If you are human, leave this field blank.

Would you allow your partner to join?

No - Individual Therapy

Yes - Couples Therapy

Not sure decide later

Let’s go over the steps involved in locating the ideal therapist for you. We’ll start off by asking some simple questions.

Counsellors & Psychologists

Select your license type *

BACP Counsellor (MBACP Registered, Accredited, or Snr Accredited)

Chartered Psychologist (HCPC)

NCS Counsellor (MNCS, FNCS)

OtherOther

Next

Where do you currently spend most of your time? *

Other online platforms like Pure

Clinic or hospital

Private practice

Community mental health agency

Teaching or counselling in an academic setting

Other clinical setting

Not currently practicing

Next

How much of your time is currently spent on administrative and/or billing related tasks? *

Up to 10% of my time

10 to 30% of my time

More than 30% of my time

Next

What makes you most interested in Pure Medical? *

To build my own private practice

To s