Consultation Form

Consultation Form

Before the treatment we will take a consultation with you to collect
the relevant information with the aim to design a safe and effective
treatment. We will suit your needs and try to achieve the best possible
results.

All information given to us is STRICTLY CONFIDENTIAL

The information below will be retained as part of your client record.
(please complete as much as possible where appropriate)

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Please provide the following contact information.......

Name

Street address

Address (cont.)

Town

County

Post code

Phone

E-mail

...and details of your GP

GP Name
Street address
Address (cont.)
Town
County
Post code
Reason for last visit?

Sex:

DoB: -- mm/dd/yy

Height: ~feet ~inches

Weight: ~pounds

Main reason for treatment?

Are you currently taking any
prescribed medication or natural remedies?

Are you receiving any form of complementary
therapy?

How would you describe your present health?

Family medical history

Medical history/operations/injuries

Muscular/skeletal problems:

Digestive problems

Nervous system

Immune system

Circulatory system

Skin:

Gynaecological problems

Allergies

Regular meals?		in hurry?
food / vitamin supplements?		water?
salt?		sugar?
coffee?		fruit juices?
soft drinks		Smoke?
Drink alcohol?		exercise?
Sleep well?		How long (hours)?
Relax easily?
How do you relax?

What are your hobbies / interests?

Do you enjoy your work?

How well do you cope with stress?

Disclaimer.

I accept that:

The information I have given is true to the best of my knowledge and I have not withheld any information concerning my health.

I understand that there is possibility of developing some minor reactions - as my body adjust to the treatment given.

I have also been made aware of contra indications. While recognising that all due care will be taken by my practitioner I am aware that my participation in the treatment is by my own choice.

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CONSULTATION FORM LONDON MASSAGE TREATMENT COMPLEMENTARY CONFIDENTIAL CLIENT RECORD