Relaxtherapy client treatment and record form (1)

Which treatment/treatments are you interested in?

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of birth

Age

Phone Number

Area code Phone number

Email

example@example.com

Next of kin and number

Date of First Session

Date

Medical history

Allergies

Any health concerns, general state of health

Are you taking any current medications/supplements?

Why would you like to receive a treatment? What would you like a treatment to help you with?

Do you smoke?

How many?

Do you drink alcohol?

How much?

Do you eat healthy?

Any problems with diet and digestion?

Amount and quality of sleep?

Do you wake up rested?

Energy levels on the scale of 1-10

Are you working?

Do you like your job?

Any spine or structural issues?

Can you lie on your back?

Do you exercise regularly?

Anything else I need to know?

Any questions you need to ask?

Are you pregnant? If yes how many weeks/months?

Enquiries/Feedback*

Before Treatment Advice

Please avoid alcohol 24 hours before treatment and be hydrated.

Come with the intention to support your healing journey.

Wear light, comfortable clothing and shoes will be removed for treatments.

Blankets are available for treatments if you wish to use.

Refreshments are available if needed such as water, herbal teas, teas and coffee.

You can bring your own refreshments.

On day of treatment please come around side of house, through gate and into the summerhouse.

Please arrive on time, if early can sit in garden seating area by the summerhouse or if wish can explore top garden while you wait.

Please message me for further information, including address and postcode.

My telephone number is 07870233341

Thank you and I look forward to seeing you for your wonderful relaxing treatment.