Consultation Form

Before your appointment, please complete the online consultation form. This allows Nuala to gain a deeper understanding of your health history, lifestyle, and personal goals, ensuring your session is fully personalised and results-focused.

Full Name

Date of Birth

Address

Phone Number

Your email

About You

Marital Status (Single / Married / Divorced / Widowed): Number of Children (If any): Current & Past Occupation(s) (If retired, what was your previous line of work?): Describe Your Lifestyle (Include activities / hobbies):

Health & Wellness

Current and Previous Health Conditions:
(Please include approximate year/time frame of diagnosis) Prescribed Medications (List each medication with dosage - include length of time on each) Allergies (Do you have allergic reactions to shellfish, nuts etc.) Food Intolerance (Do you have intolerance to dairy, wheat etc.) Supplements (Currently taking) Blood Type (Add blood type if known. If unsure leave blank.)

Current Symptoms

List symptoms (Example - headache, fatigue, pains, sleep issues etc.) Was there a trigger or cause for the health issue?

Digestion Issues

Please check any of the conditions below that apply to you

Your Daily Food Habits

Are your daily meals home prepared or is it typically grab and go readymeals? Do you eat a balanced diet? (A balanced diet includes regular servings of fruits, vegetables, whole grains, and sources of protein like meat and fish.) Sugary foods (Do you regularly eat high sugar foods like sweets, cakes and biscuits and would you crave this type of food?) Drinks (List your typical daily drinks, for example water, juice, fizzy drinks, high energy drinks etc.) Caffeine intake (On a daily basis, do you regularly drink tea and coffee. If coffee is it percolated?)

Energy Levels

Does your energy levels fluctuate throughout the day? (Please describe)

Are You Sleeping Well?

Describe your sleep pattern (Example - broken, difficulty getting to sleep etc.)

Mental Wellbeing

Describe your mental health (Is there issues in your workplace, problems at home with family etc.)

Medical History

Your past medical history (List past operations, hospital stays or other medical issues you think could be relevant)

I accept treatment from Nuala O'Hare as a Bio-Kinesiologist and Bio-Resonance therapist. I understand that Bio-Kinesiology and Bio-Resonance are complementary therapies to be used in conjunction with, and not as an alternative from, medical treatment. I consent to the processing of my personal data by Nuala O'Hare in accordance with the Data Protection Act 2018, solely for the purposes of providing me with Bio-Kinesiology/Bio-Resonance treatment in this and any further consultation which I may have. The personal data may be retained by Nuala O'Hare for seven years from the date of such last consultation. I understand it will not be disclosed to any third parties or transferred out of the U.K and I may request a copy of it at any time. My typed signature below is my consent.

Signature (type name if signing this form electronically)

Date Signed