This questionnaire has been developed to establish a clearer analysis of your individual concerns. Completion is voluntary and is kept as part of your clinical record. This questionnaire may be repeated to reassess your progress.

You only complete this questionnaire if you are a registered patient at Intus and have been requested to do so to complete your registration.

Please note:

• Your information will get sent directly through to our medical records and will not be stored anywhere else.
• Items marked * indicate mandatory fields.