Consultation Form

Please complete the following consultation form prior to your first visit with me for treatment, this is a legal required and all information is held securely inline with GDPR and in confidence.

Personal details

First nameLast nameDate of Birth

Address details

Street addressAddressline 2CityCountry
Post code

Contact details

Telephone numberE-mail address

GP details

Doctors nameDoctor surgery full addressDoctor surgery telephone number

Health related questions

Have you had any recent illnesses?
Are you on any current medication?
Do you have any allergies
Have you had any recent operations?
Do you have any muscular problems?
Do you have any skeletal problems?
Do you have any digestive problems?
Do you have any circulatory problems?
Do you have any nervous system problems?
Do you have any immune system problems?
Do you have heart disease?
Do you have any current cuts/ abrasions?
Do you have any current bruises?
Do you have any thrombosis issues?
Do you have any undiagnosed lumps?
Do you have diabetes?
Do you have any reduced sensation?
Do you currently have any infectious diseases?
Do you have any cancer diagnosis or waiting for a diagnosis?
What are your sleep patterns?What are your general energy levels?What is your daily water intake?How often do you excercise?What is your weekly alcohol consumption?Are you a smoker?
If you have answered 'Yes' to any of the questions above, please provide more details here

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