Personal DetailsClient Name*Profession*GP Address*Last visit to the Doctor*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age group*Under 2020-2930-3940-4950-5960+Lifestyle* Active Sedentary Both No. of children(if applicable)Date of last periodMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(if applicable)Contraindications that require medical permission Pregnancy Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions) Haemophilia Any condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, Coach Medical oedema Osteoporosis Arthritis Anxiety/stress/depression Epilepsy Recent operations Diabetes Myositis ossificans Acute trauma Open wounds Acute soft tissue injury Periostitis Risk of haemorrhage Asthma Any dysfunction of the nervous system e.g. Multiple sclerosis, Parkinson’s disease, Motor neurone disease Bell’s Palsy Trapped/Pinched nerve (e.g.sciatica) Inflamed nerve Cancer Postural deformities Spinal cord conditions (e.g.cerebral palsy) Kidney infections Whiplash Slipped disc Undiagnosed pain Acute rheumatism Thyroid Disorders Severe Allergies (that require medical attention e.g. nuts) Taking prescribed medication Tumour Frostbite Bursitis (select if/where appropriate)Please give details of any other diagnosed medical condition that is not listed aboveWitten permission required by GP/Specialist* Yes No (If any of the boxes above are ticked, a disclaimer form should be completed by the client and attached to the consultation form)Personal Information(select if/where appropriate)Muscular/Skeletal problems Back Aches/Pain Stiff joints Headaches Digestive problems Constipation Bloating Liver/Gall bladder Stomach Circulation Heart Blood pressure Fluid retention Tired legs Varicose veins Cellulite Kidney problems Cold hands and feet Gynaecological Irregular periods P.M.T Menopause H.R.T Pill Coil Other OtherNervous system Migraine Tension Stress Depression Immune system Prone to infections Sore throats Colds Chest Sinuses Regular antibiotic/medication taken* Yes No Which regular antibiotic/medication takenHerbal remedies taken?* Yes No Herbal remedies takenAbility to relax* Good Moderate Poor Sleep patterns* Good Poor Average number of hours a sleepDo you see natural daylight at work?* Yes No Do you work at a computer?* Yes No If yes, how many hours?*Do you eat regular meals?* Yes No Do you eat in a hurry?* Yes No Do you take any food/vitamin supplements?* Yes No Which food/vitamin supplements do you take?*What do you eat for …BreakfastLunchDinnerDo you eat (regularly) Sweet things Added salt Added Sugar Do you restrict any food groups?* Yes No What food groups do you restrict?*TeaDaily volume (ml)CoffeeDaily volume (ml)Fruit juiceDaily volume (ml)WaterDaily volume (ml)Soft drinksDaily volume (ml)OtherDaily volume (ml)Do you suffer from food allergies?* Yes No What food allergies do you have?*Does stress affect your eating habits?* Yes No If so, how?*Do you smoke?* Yes No How many per day?*Do you drink alcohol?* Yes No Number of units per week?*Do you exercise?* None Occasional Irregular Regular Type of exerciseWhat is your skin type?* Dry Oily Combination Sensitive Dehydrated Do you suffer/have you suffered from? Dermatitis Acne Eczema Psoriasis Allergies Hay Fever Asthma Skin cancer Do you suffer from allergic skin reactions?* Yes No If so, to what?*Stress at workPlease enter a number from 1 to 10.Stress at homePlease enter a number from 1 to 10.Dominant hand Right handed Left handed Please give a brief description of the issue or reason for treatmentDeclaration* By clicking submit I confirm that all information given is true and that I consent to treatment
