PERSONAL DETAILS |
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| Date: | Client | ||
| Code: | |||
| Surname: | Forename: | Male / Female | |
Address:
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Occupation: | Marital Status: Children: |
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| Tel: | Email: | ||
| Date of Birth: | Age: | ||
MEDICAL DETAILS |
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Doctor's Name and Address:
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Current State of Health: | ||
| Tel: | Allergies: | ||
| Contact Lenses? | |||
| Dentures? | |||
| Do any of the following conditions apply to you? (Please tick where appropriate) | |||
| Contagious disease | Diarrhoea | Drugs (recreational) | |
| Fever | Infectious disease | Residual Malaria | |
| Vomiting | Cancer | ||
| Arthritis | Asthma | Bells Palsy | |
| Cardiovascular Condition | Diabetes | Epilepsy | |
| Heart Condition | Hyper/Hypotension | Inflamed Nerve | |
| Kidney Infection | Medical Oedema | Nervous/Psychotic Condition | |
| Osteoporosis | Phlebitis | Pinched Nerve | |
| Postural Deformities | Pregnancy | Prescribed Medication | |
| Recent Operation | Rheumatism (acute) | Slipped Disc | |
| Spastic Condition | Thrombosis | Trapped Nerve | |
| Undiagnosed Pain | Whiplash | ||
| Abrasions | Bruises | Cervical Spondylitis | |
| Cuts | Gastric Ulcer | Haematoma | |
| Hernia | Hormonal Implants | Menstruation | |
| Neck Condition | Recent Fracture | Scar Tissue | |
| Skin Disease | Sunburn | Scar Tissue Undiagnosed Lumps/Bumps | |
| Undergoing GP or Specialist Treatment? | Varicose Veins | ||
| If you have ticked any of the boxes above please give details here: | |||
| [Therapist] [Only] | |||
| [Written Permission Required?] | [Yes / No] | [If yes specify GP or Self] | |
LIFESTYLE QUESTIONNAIRE |
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| DIET | |||
| How much of the following do you consume? | |||
| Vegetables (Portions per day) | Fruit (portions per day) | ||
| Meat (portions per week) | Fish (portions per week) | ||
| Dairy (amount per week) | Ready meals/take away (no. per week) | ||
| Coffee (cups per day) | Tea (cups per day) | ||
| Fizzy drinks (no. per week) | Water (amount per day) | ||
| Salt (amount added per week) | Sugar (amount added per week) | ||
| Alcohol (Units per week) | Tobacco (amount per day) | ||
| EXERCISE | |||
| Describe the exercise you do in a week: | |||
| GENERAL: | |||
| Rate your stress levels at Home 1-10 where 1 is minimal and 10 is extreme: | |||
| Would you describe your sleep pattern as: | Poor | Average | Good |
| Would you describe your energy level as: | Poor | Average | Good |
| CONSENT: | |||
| Please read and sign the following statement: | |||
| I confirm that the treatment I will receive has been explained to me by the therapist and I understand what it involves. It has been offered to me as complementary to conventional medicine and I understand that it is not an alternative to or a replacement for any conventional therapy or medicine I require. I have answered all medical and lifesttyle questions put to me to the best of my ability and in all truthfulness. I participate in this therapy of my own free will and at my own risk. | |||
| Name: | |||
| Date: | |||
| Client signature: | |||