Your Information
Required fields are followed by *
Name *
Phone *
Date of Birth * Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925
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
