Total Body Therapy

Request an Assessment Form

Due to current demand, all new patient requests are reviewed before appointments are offered.

Please complete the brief form below. If your case is suitable, our team will contact you with the next steps.

Personal Details

Your Current Concern

What is the primary issue you would like help with?

How long have you been experiencing this issue?

Less than 4 weeks 1–3 months 3–6 months 6–12 months More than 12 months

Which area of the body is most affected?

Head / Jaw Neck Shoulder Upper Back Mid Back Lower Back Hip / Pelvis Knee Ankle / Foot Multiple Areas Other

Have you previously sought treatment for this issue?

Yes No

If yes:

What treatments have you tried?

How much is this issue affecting your daily life?

Minimal Moderate Significant Severe

Suitability Questions

What outcome are you hoping to achieve?

Are you currently under the care of any of the following?

X-Ray MRI CT Scan Ultrasound No

Is there anything else Craig should know before reviewing your request?

Final Declaration

[YES]

I confirm the information provided is accurate to the best of my knowledge.

[YES]