Derek Climpson BSc Hons, Lic Ac, MBAcC, MBMAS, MSTAT

Member: British Acupuncture Council
British Medical Acupuncture Society

Acupuncture Clinics:
Chelmsford – Monday
Brentwood – Tuesday
Leigh-on-Sea – Thursday

Derek Climpson BSc Hons, Lic Ac, MBAcC, MBMAS, MSTAT

Member: British Acupuncture Council
British Medical Acupuncture Society

Acupuncture Clinics:
Chelmsford – Monday
Brentwood – Tuesday
Leigh-on-Sea – Thursday

Tel. 07702 631 259

Email: derekclimpson@yahoo.co.uk

Tel. 07702 631 259

derekclimpson@yahoo.co.uk

Consultation Form

Medical history and intake form

Please complete this form as accurately as possible – it helps to provide you with the best possible treatment. It may be easier to complete the form on a desktop or laptop computer.

How will you be paying?

Please indicate which of the following skin problem / diseases / symptoms you have NOW

Please indicate if you have any of the following heart / cardio vascular problems NOW

Please indicate if you have any of the following respiratory problems NOW

Please indicate if you have any of the following Gastrointestinal / digestive problems NOW

Please indicate which of the following hormonal imbalances you have NOW

Please indicate if you have any male reproductive issues NOW

Please indicate if you have any of the following female reproductive problems NOW

Please indicate if you have any of the following autoimmune, viral or inflammatory conditions NOW

Please indicate which of the following ear/nose/throat problems you have NOW

Please indicate if you have any of the following oral diseases NOW

Please indicate if you have any of these general problems NOW

Please indicate if you take any of the following medication/recreational drugs NOW

How will you be paying?

Please indicate which of the following skin problem / diseases / symptoms you have NOW

Please indicate if you have any of the following heart / cardio vascular problems NOW

Please indicate if you have any of the following respiratory problems NOW

Please indicate if you have any of the following Gastrointestinal / digestive problems NOW

Please indicate which of the following hormonal imbalances you have NOW

Please indicate if you have any male reproductive issues NOW

Please indicate if you have any of the following female reproductive problems NOW

Please indicate if you have any of the following autoimmune, viral or inflammatory conditions NOW

Please indicate which of the following ear/nose/throat problems you have NOW

Please indicate if you have any of the following oral diseases NOW

Please indicate if you have any of these general problems NOW

Please indicate if you take any of the following medication/recreational drugs NOW

11 + 4 =