Personal Details

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Please complete this form prior to attending the session with Dr Barnes.

In my family we suffer from (select all that apply)

None

Diabetes I/II

Heart

High/low blood pressure

Anaemia

Stress

Depression

Mental

Alcoholism

Dependence upon a drug or medicine

Asthma

Epilepsy

Sexuality +/-

Gyni

Cancer

Paralysis

Parkinson

Alzheimer

Skin

Bones

Eyes

Malaria

Tuberculosis

Cholera

Chikungunia

Dengue

SARS

Corona

Other

Your details are kept entirely confidential.