Home Contact us Online Consultation Form Explain clearly what are your symptoms, what medications you are currently taking and how many doses. Initial response time within 24 hours! Or Contact Mr A S Kamal on 07956662877 * Mandatory Fields Patients Details Your Details       Surname: * Forenames: * Date Of Birth: * Address: *       Post Code: Marital Status: Married Single Divorsed Seperated Living with Partner Occupation: Choose Menu Professional Manager Factory Worker Unemployed Self Employed Other Gender : Male Female Daytime Tel: * Mobile: (optional) Evening Tel: * Email: *     Your Health Height: * Weight:* Do you exercise on a regular basis: Please Select Yes No Any on going Medication or Treatment. Please Select Yes No If Yes Please Describe Below Your Fitness: Please Select Very fit Normal Over Weight Under Weight     Your Health - Do You Suffer From The Following: Digestive System Diarrhoea Please Select Yes No Indigestion Please Select Yes No Constipation Please Select Yes No Irritable Bowel Please Select Yes No Eating Disorder Please Select Yes No Crohn's Disease Please Select Yes No Bloated Stomach Please Select Yes No Piles Of Haemorrhoids Please Select Yes No Problems concerning Women Fibroid Please Select Yes No Hot Flush Please Select Yes No Night Sweat Please Select Yes No Forgetfullness Please Select Yes No Loss of Libido Please Select Yes No Painful Period Please Select Yes No Endometeriosis Please Select Yes No Pins & Needles Please Select Yes No Irregular Periods Please Select Yes No Vaginal Dryness Please Select Yes No Tearful/Agitated Please Select Yes No   Menstrual Bleeding Please Select Yes No   Thrush / Discharge Please Select Yes No   Pregnancy / Fertility Please Select Yes No Lack of Concentration Please Select Yes No Premenstrual Tension Please Select Yes No   Polycystic Ovary Syndrome Please Select Yes No   Problems concerning Men Impotence Please Select Yes No   Low Sperm Please Select Yes No   Enlarged Prostate Please Select Yes No   Erectile Weakness Please Select Yes No   Premature Ejaculation Please Select Yes No Muscular / Pain Related RSI Please Select Yes No Scatica Please Select Yes No Scoliosis Please Select Yes No Bad Knee Please Select Yes No Stiff Knee Please Select Yes No Neuralgia Please Select Yes No Back Pain Please Select Yes No Tendonitis Please Select Yes No Tennis Elbow Please Select Yes No Golfer's Elbow Please Select Yes No Trapped Nerve Please Select Yes No Frozen Shoulder Please Select Yes No Mental/Neurological Stress Please Select Yes No Stroke Please Select Yes No Anxiety Please Select Yes No Phobias Please Select Yes No Tremor Please Select Yes No Migraine Please Select Yes No Headache Please Select Yes No Insomnia Please Select Yes No Depression Please Select Yes No Facial Palsy Please Select Yes No Panic Attacks Please Select Yes No Cerebral Palsy Please Select Yes No Shingles / Herpes Please Select Yes No Multiple Sclerosis Please Select Yes No Feeling Run Down Please Select Yes No Loss Of Smell / Taste Please Select Yes No Low Energy / Tiredness Please Select Yes No Skin / Hair Disorders Acne Please Select Yes No Herpes Please Select Yes No Eczema Dry Please Select Yes No Eczema Wet Please Select Yes No Vitiligo Please Select Yes No Psoriasis Please Select Yes No Hair Loss Please Select Yes No Dermatitis Please Select Yes No Others Please Select Yes No If Yes Please Describe Below Respiratory System Asthma Please Select Yes No Sinusitis Please Select Yes No Hay Fever Please Select Yes No Bronchitis Please Select Yes No Emphysema Please Select Yes No Chronic Cough Please Select Yes No Angina Attacks Please Select Yes No Other Internal Conditions Obesity Please Select Yes No Diabetes Please Select Yes No Tinnitus Please Select Yes No Hepatitis Please Select Yes No Palpitations Please Select Yes No Fluid Retention Please Select Yes No Hypothyroidism Please Select Yes No High Cholesterol Please Select Yes No Bed Wetting Please Select Yes No Incontnency Please Select Yes No Blood In Urine Please Select Yes No Frequent Urination Please Select Yes No Description Of Illness: *

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