Date:   Client
Surname: Forename: Male / Female





Marital Status:


Tel: Email:
Date of Birth: Age:  

Doctor's Name and Address:



Current State of Health:
Tel: Allergies:  
  Contact Lenses?  
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]
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)  
Describe the exercise you do in a week:
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
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.
Client signature: