HomeOur ServicesDirectionsTestimonialsINTRODUCTIONCASES 1-6CASES 7-13CASES 14 - 21Tai Chi and QiGong Cases TC1 TO TC5CASE STUDY SUBMISSION FORM

If you wish to participate in this study, please download and complete the following form.  E mail the completed paper to us and send the hard printed copy signed by both you and a witness to the effects of the treatment. 
 
Some people have experienced problems with a direct download.  Some software does not support this site text.  If so, highlight and edit 'copy' and paste into your usual word text blank page.  If that does not work, ring me and I will e mail it over to you.  Tony

NAME   Mr Mrs Miss
ADDRESS 

CONTACT DETAILS 


Name of Client/Patient/Student 
                                               

AGE………….   SEX……… 
Which Clinic did you attend    The Chi Clinic  Other
Which class or course of classes. 
Who was the therapist or teacher: - Tony Hardiman / Vicky Ahern, Other………............….. 

How did you find the Clinic….On recommendation- Website- Shop- Other 

What was the condition for which you sought help
When was the date (s) of your appointment or class.
Was the treatment for you or a minor. 

Did you find the premises easy to locate / or / was the home visit prompt.
Was the information given prior to your visit clear and useful
Were the premises clean and presentable
Were the facilities clean and adequate 

What were your first impressions
 

Were you made to feel welcome
Was your condition discussed in full
Was the treatment suggestion clear and adequate
Did you sign a full consent form

Were you made fully aware of the need to undress
Did you feel that the treatment was worth the cost.

 PLEASE NOW, IN YOUR OWN WORDS DESCRIBE THE EVENTS LEADING TO YOUR ATTENDANCE FOR TREATMENT AND WHAT WAS DONE TO ALLEVIATE THE CONDITION, HOW EFFECTIVE WAS THE TREATMENT AND ANYTHING THAT MAY ASSIST IN GIVING A FULL AND DETAILED ACCOUNT OF THE WORTH OF THE TREATMENT.  USE AS MUCH SPACE AS YOU WISH AND SCROLL DOWN THE PAGE.       



DECLARATION MUST BE SIGNED I give unreserved permission for the above testimony to be used in a public volume and for the release of comments by the therapist who treated me and discreet extracts from my Clinic case notes to be used in public with anonymity in the public document. SIGNED DATE 

FAMILY MEMBER OR FRIEND 
NAME
ADDRESS                                                
CONTACT DETAILS

 I certify that the above is a true record of the events to the best of my knowledge. I make further comment as follows. Use as much space as you wish and as many pages necessary.  We are also looking at the effects of illness and the recovery on the families.      Signed                                               Date

NAMES AND PERSONAL DETAILS WILL BE OMITTED IN THE PUBLISHED RESPONSES.

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