Consultation FORM
From Holistic Massage student Miyoung
First name: Surname:
Address:
City:
Post code:
Tel:
Occupation:
Dr’s name:
Address:
Medical History
(For Client’s Safety)
Have you ever suffered from any of the following?
[Give details]
Asthma yes/no
Respiratory Problems yes/no
Diabetes yes/no
Endocrine problems yes/no
Heart Condition yes/no
Epilepsy yes/no
Cancer yes/no
Acute joint conditions yes/no
Varicose Veins yes/no
High/Low blood pressure yes/no
Skin disorders yes/no
ME yes/no
Migration, Headaches yes/no
Problems with veins/arteries yes/no
Nervous disorder yes/no
Infectious diseases yes/no
Allergies yes/no
Heartburn yes/no
Any other information:
Medication:
Homeopathy:
Date of last period:
Recent operation:
Emotional state:
Do you feel worried? Rarely/sometimes/often
Do you get neck, shoulder or back pain? Rarely/sometimes/often
How are you energy levels? Low/moderate/high
Do you have trouble falling asleep or staying asleep? Rarely/sometimes/often
Stress levels: 1 2 3 4 5 6 7 8 9 10
Diet:
Daily diet contains how many of the followings?
Fresh fruit: proteins: fibre:
Fresh vegetables: salt: sugar:
Daily beverage intake: Tea: Toffee: Other caffeinated drinks:
Soft drink: Water:
Alcohol consumption: no/ light/medium/heavy
Units per week?
Exercise? None/ occasional/ irregular/ regular
Type of exercise:
Skin type:
Oily
Reason for visit:
Declaration:
I declare the information I have given is correct as far as I am aware. I am willing to proceed with the treatment. I understand that this treatment does not substitute medical treatment. Information given by me is treated in strictest confidence.
(Client)
Signature: date:
(Therapist: Miyoung Kim)
Signature: date: