THERAPEUTIC MASSAGE IN LONDON ALTERNATIVE THERAPIES COMPLEMENTARY HEALTH HOLISTIC TREATMENT HOME SERVICE LONDON CONSULTATION FORM ENGLAND UK www.massagelondon.info info .info PICTURE IMAGE LOGO PICTURES

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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)

[FrontPage Save Results Component]

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