TNC Direct - Patient Information
Date (*)
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Patient Name
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Your Name (if different)
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Gender
Male
Female
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Age
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How can we contact you
Email
Work Phone
Home Phone
Mobile
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Your Email
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Your Phone
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Why have you contacted TNC Direct today?
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Please answer any of the following questions which are relevant to you as fully as possible:
What caused the problem?
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Where is it located?
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What does it look like?
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What does it feel like/what is the pain sensation?
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What makes it better? i.e. rest, pressure
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What makes it worse? i.e. overuse, cold weather
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Is there any time of day or night it is worse?
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Is there anything else you can tell us which may be relevant?
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Have you ever had homeopathic treatment for this problem before? If so, which remedy and did it help?
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How would you like to receive your prescription?
Post
Collect
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