Staircase Form

“Every person is different, there are unique symptoms
particular to the individual.”

History of your health

To know your best treatment we need a short overview of important events regarding your physical and psychological development, from birth to present. Problems, illnesses, operation, taumatic events, etc.

We have created a staircase form that can be download and filled in for uploading onto our form below.

pdf-logoMy Staircase – Download and print to fill in
Download My Staircase for printing. – PDF 39KB


word_logoMy Staircase – Download and fill in on your computer
Download My Staircase for your computer. – DOC 50KB


pdf-logoMy Staircase – View an example
View an example of My Staircase. – PDF 80KB


Your health at present (current state)

* indicates required field

Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.


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