Pre treatment Questionnaire:

Please as truthfully and fully as possible.

    Personal Details:

    Gender

    Age Group

    Lifestyle

    Last visit to the Doctor

    CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment. (select if/where appropriate):

    If applicable please give details of the above conditions:

    CONTRAINDICTIONS THAT RESTRICT / PREVENT TREATMENT (select if/where appropriate):

    If applicable please give details of the above conditions:

    If written permission required, please bring on the day:

    Personal Information, Please check any boxes that apply

    Muscular/Skeletal Problems:

    Digestive Problems:

    Circulation:

    Gynaecological:

    Nervous System:

    Immune system:

    If applicable please give details of the above:

    Regular antibiotic/medication taken?

    Herbal Remedies taken?

    Ability to Relax:

    Sleep Patterns

    Do you see natural daylight in your workplace?

    Do you work at a computer?

    Do you eat regular meals?

    Do you eat in a hurry?

    Do you take any food/vitamin supplements?

    Do you suffer from food allergies?

    Do you suffer from eating disorders?

    Do You Smoke?

    Do You Drink Alcohol?

    Do You Exercise?

    What is your skin type?

    Do you suffer/have you suffered from:

    If applicable please give details of the above conditions:

    Stress Levels:

    Anxiety Levels