Under 2021-3031-4041-5051-60Over 60
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):
PregnancyCardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)HaemophiliaAny condition already being treated by a GP or another complementary practitionerMedical oedemaOsteoporosisArthritisNervous/Psychotic conditionEpilepsyRecent operationsDiabetesAsthmaAcute rheumatismAny dysfunction of the nervous system (e.g. Multiple sclerosis, Parkinson’s disease, Motor neurone disease)Bell’s PalsyTrapped/Pinched nerve (e.g. sciatica)Inflamed nerveCancerPostural deformitiesCervical spondylitisMuscular spasm conditionsKidney infectionsWhiplashSlipped discUndiagnosed painTaking prescribed medication
If applicable please give details of the above conditions:
CONTRAINDICTIONS THAT RESTRICT / PREVENT TREATMENT (select if/where appropriate):
FeverContagious or infectious diseasesUnder the influence of recreational drugs or alcoholDiarrhoea and vomitingSkin diseasesUndiagnosed lumps and bumpsLocalised swellingInflammationVaricose veinsCutsBruisesAbrasionsSunburnHormonal implantsMenstruation (abdomen -first few days)HaematomaHerniaRecent fractures (minimum 3 months)Gastric ulcersAfter a heavy mealConditions affecting the neckPregnancy (abdomen)
If written permission required, please bring on the day:
Personal Information, Please check any boxes that apply
HeartBlood PressureFluid RetentionTired LegsVaricose VeinsCelluliteKidney ProblemsCold Hands and Feet
Prone to infectionsSore throatsColdsChestSinuses
If applicable please give details of the above:
Regular antibiotic/medication taken?
YesNoIf Yes please state
Herbal Remedies taken?
YesNoIf Yes please state
Ability to Relax:
GoodPoorAverage number of hours
Do you see natural daylight in your workplace?
Do you work at a computer?
yesNoIf Yes how many hours?
Do you eat regular meals?
Do you eat in a hurry?
Do you take any food/vitamin supplements?
yesNoIf Yes which ones?
Do you suffer from food allergies?
Do you suffer from eating disorders?
BingeingOver EatingUnder Eating
Do You Smoke?
YesNoIf Yes how many a day?
Do You Drink Alcohol?
YesNoIf Yes how many units a day?
Do You Exercise?
NoneOccasionalRegularWhich types of exercise do you do?
What is your skin type?
Do you suffer/have you suffered from:
DermatitisAcneEczemaPsoriasisAllergiesHay FeverAsthmaSkin cancer
All major credit and debit cards accepted.