Healthcare Needs Assessment | Metta Health | Medical Concierge & Bespoke UK Private Healthcare

Health Needs Assessment Form

Please complete the form below if

You would like us to arrange an e‑consultation for you, or

You would like to come to the UK for medical treatment.

Please provide as much relevant medical information as possible.

Once we receive your completed form, we will contact you within 24 hours.
Please note that any personal information you submit to Metta Health will be held in the strictest of confidence according to our Privacy Policy*

Tell us a bit about yourself

Full Name (required)

Please provide your full name.

Date of Birth (required)

Please provide your date of birth.

Sex Assigned at Birth (required)

Male

Female

Other

Please provide your sex at birth.

Address Line 1 (required)

Please provide the first line of your home address.

Address Line 2

Please provide the second line of your home address.

Town/City (required)

Please provide your city.

Region/State (required)

Please provide your state.

Post/Zipcode

Please provide your zip code.

Email (required)

Please provide your email address.

Phone (required)

Please provide your phone number.

* We comply with the European Union’s General Data Protection Regulation (GDPR). Please see our Privacy Policy for more information.

Tell us about your health problem

A qualified doctor has confirmed a diagnosis for my complaint. (highly recommended)

What symptoms are you experiencing? (e.g. pain, swelling, numbness) (required)

Please provide your symptoms.

Approximately how long have you been experiencing these symptoms? (required)

Please tell us how long you've been experiencing your symptoms.

What treatment have you had so far? (required)

Please provide details of any treatments you have had to date.

If you are experiencing pain please indicate the level of pain.

Please tell us what medications you are currently taking.

Tell us about your medical history

Have you ever had any of the following?

If you have any other health conditions, please provide details.

Any additional information you may want to provide.

Health Needs Assessment Form

Tell us a bit about yourself

Tell us about your health problem

Tell us about your medical history

Have you ever had any of the following?

Do any of the following apply to you?