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Your Information

Required fields are followed by *.

Name *

Phone *

Date of Birth *
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Email *

Do you suffer from any injurie, aches or pains in muscles or joints? Y/N *

Have you had any Skeletal injuries, breaks, fractures or authorities? Y/N *

Do you suffer from any circulatory problems such as heart issues, angina, thrombosis, varicose veins, fluid retention or any family history in this? Y/N *

Do you have any blood pressure issues such as low or high blood pressure? Y/N *

Do you suffer from swelling in Lymph glands, tonsils, adenoids or have frequent infections? Y/N *

Do you suffer from Kidney or bladder infections, cystitis, pain or pressure when passing urine or prostate problems? Y/N *

Do you have any digestive issues such as constipation, bloating, heartburn or cramps? Y/N *

Do you have any respiratory issues such as bronchitis, asthma, sinusitis, ear infections or cough? Y/N *

Do you suffer from headaches, migraine, tension, stress, anxiety or depression? Y/N *

Are you currently pregnant? Y/N *

Do you have any skin conditions such as dermatitis, eczema, psoriasis or skin allergies? Y/N *

Is there any history of cancer within the family? Y/N *

Do you have any allergic reactions for example to a specific food, additive or medication? Y/N *

Do you have any sleeping problems, difficulty falling asleep or waken feeling exhausted? Y/N *

How is your diet? E.g Normal, reduction, diabetic, gluten free, fatty food?

On a scale of 1-10 (10 being the highest), how stressed do you currently feel in daily life? *

I hereby declare that I have answered the consultation fully and I have not withheld any information that may affect the outcome of the treatment. Treatment has been fully explained and I have been made aware of any possible reactions that could occour. I know of no reason why I cannot undertake this treatment. It is my responsibility to notify the Therapist or any medical changes that may affect any treatment either now or in the future *

Notes