CONSULTATION FORM
Your Details (Part 1 of 2)
First Name
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Last Name
*
Phone
*
Email
*
Date Of Birth (Day)
Date Of Birth (Month)
Date Of Birth (Year)
Address
*
City
*
Postal code
*
Occupation
*
Health & Medical History (Part 2 of 2)
Do you have any injuries and/or complains at present?
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NO
YES
Details on injuries and/or complaints (please indicate including year):
Have you had any operations in the last 5 years?
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NO
YES
Details Of Operations (please indicate including year):
Have you suffered / suffering from any of the following conditions:
Asthma
Diabetes
Epilepsy
Stroke
Heart Attack
Ostoeporosis
Migraine
Cancer
Varicose Veins
Blood Clot / DVT
High / Low Bloody Pressure
If ticked yes to any of the above, please share details.
Are you taking any recreational drugs, natural/pharmaceutical medication?
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NO
YES
Details of any drugs:
Do you do regular exercise?
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NO
YES
If yes, please list hours per week and what type of exercise:
Do you have any allergies?
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NO
YES
Details on any allergies:
Do you suffer from any of the following (tick any that apply):
Anxiety
Phobias
Depression
Postnatal Depression
Nervousness
Anger
Menopause
Addiction
Mood Swings
Insomnia
Anorexia
PMT
Please state if you have or are suffering from any further conditions or ailments that are not listed and you would like your therapist to be aware of:
Are you pregnant and/or lactating?
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NO
YES
N/A
Signature (Sign Your Name Here)
*
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