Tynemouth's premier chiropractic care facility

New Patient history: Massage therapy 

Please fill in as much of this form as you can and tick where appropriate.

Areas marked with * must be filled in.

Full name:*


Email: *


Home phone:

HEALTH - do you suffer from any of the following? 

If so please describe briefly.

BOOK an appointment
to see Mandy:

Her hours are currently, Thursday from 2pm – 6pm

Schedules are currently subject
to change.

Are you pregnant?

Heart condition?

Blood pressure: high/low

Epilepsy or Diabetes

Respiratory disorders

Circulatory disorders, eg, fluid
retention, kidney, varicose veins

Skin sensitivity 


Do you suffer with arthritis,
joint or muscular problems

Other medical problems

Taking any medication?



Active or sedentary


Do you smoke?

Alcohol consumption

Your aims from this treatment?

Naturally Chiropractic:  1a St Oswins Place, Tynemouth NE30 4RQ

t: 0191 259 6777  | e: info@naturallychiropractic.co.uk

I understand that this treatment is taken at my own risk and Mind & Body will assume no liability of any kind.  I have answered the questions to the best of my knowledge and will undertake to inform you of any alteration to the above.

Mind and Body is an independently operated company and Naturally Chiropractic cannot be held liable, financially or legally responsible for Mind & Body.

Please note that by submitting this form you are giving us permission to contact you using the methods listed above. Your details will be held on the Naturally Chiropractic dates on behalf of Mind and Body but will not be passed to third parties at any other time. You will be added to our email newsletter, which will keep you appraised of events and important information, such as how we are handling CoVid. You can unsubscribe at any time.