Medical questionnaire client consultation form Please complete and submit the consultation form below: Fields marked with an asterisk * are required fields Client Name *Telephone No. (Day) Date *Date of Birth Telephone No. (Evening) Profession *Email Address Client Address Gender *MaleFemale Reason for seeking therapy *Lifestyle *ActiveSedentaryDate and reason for last visit to your GP *GP name, address and telephone no. * CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION (select if/where appropriate)– in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment. Any condition already being treated by a GP or another complementary practitioner (Please give more information below)Cardiovascular condition - ThrombosisCardiovascular condition - PhlebitisCardiovascular condition - HypertensionDysfunction of the nervous system - Muscular sclerosisDysfunction of the nervous system - Parkinson’s diseaseDysfunction of the nervous system - Motor neurone diseaseBells PalsyPregnancyHaemophiliaMedical oedemaOsteoporosisArthritisNervous/Psychotic conditionsEpilepsyRecent operationsDiabetesAsthmaAny condition already being treated by a GP or another complementary practitioner information Name(s) of Prescribed medication(s) and reason Date of last period (if applicable) CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate) FeverContagious or infectious diseasesUnder the influence of alcohol or recreational drugsDiarrhoea and vomitingSkin diseasesUndiagnosed lumps and bumpsLocalised swellingInflammationVaricose veinsBreast feedingWhiplashSlipped discGastric ulcersHerniaAfter a heavy mealHypersensitive skinSunburnCutsBruisesAbrasionsAbdomen PainHaematomaRecent fractures (minimum 3 months)Cervical (neck) spondylitisScar tissues (2 years for major operation and 6 months for a small scar)Other (Please give more information below)Other contraindications information Muscular/Skeletal problems BackAches/PainsStiff JointsHeadachesDigestive problems ConstipationBloatingLiver/Gall bladderStomachCirculation HeartBlood pressureFluid retentionTired legsVaricose veinsCelluliteKidney problemsCold hands/feetGynaecological Irregular periodsP.M.TMenopauseH.R.TPillCoilOtherNervous system MigraineTensionStressDepressionImmune system Prone to infectionsSore throatsColdsChestSinusesHerbal remedies taken Do you suffer/have you suffered from DermatitisAcneEczemaPsoriasisAllergies Hay feverAsthmaOther (Please give more information below)Other allergies information Do you take any food/vitamin supplements? *YesNoIf YES, please list food/vitamin supplements: Do you suffer from food allergies? *YesNoIf YES, please list food allergies: WRITTEN PERMISSION REQUIRED BY: GP/SpecialistInformed consentClients signature required during appointment if completing on line NEWSLETTER OPT-OUT If you DO NOT wish to receive further information regarding our special offers or new treatments, please OPT-OUTOPT-OUT VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
