Client Consultation Form

Have you ever had:

When was the last time you received a treatment?

How did you hear about me?

Name

First NameLast Name

Age

Date of Birth

Date

Occupation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Reason for your visit

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Relation

GP Name and Address

List past surgeries or major medical problems/illness

List of Medication

Do you have any allergies? If yes, please list all your allergies

Please select if you suffer from any of these conditions

Related to the ear- please select if any of the following conditions apply to you

**Women's Health- Please select if any of the following symptoms conditions apply

Is there any possibility you could be pregnant?

Have you given birth in the last 18 months?

**If trying to conceive, for how long have you been trying?

**Have you and/or your partner done any fertility tests? Please add any important information here including any undergoing treatments including, medication, hormonal imbalances or medical diagnose if applicable.

***ONLY FOR PREGNANCY- Please select if any of these apply

***At what week of your pregnancy stage are you at this moment?

***Whas this pregnancy conceived naturally?

Other

***What test/ scans have you done?

***Due delivery date:

Date

***Have you ever had any complications during your pregnancy?

***Any history of miscarriadges?

***Is this your first pregnancy?

***If no to the two above answers, how many other children do you have and ages?

***Are you undergoing any physical activities during your pregancy? If yes, please list them

Do you smoke?

From 1 to 10 (10 being the highest), rate your levels of stress at work and home

What type of pressure do you like?

From 1 to 10 (10 being the healthiest), how healthy do you consider your diet to be?

My sleep is...

How would you rate your general state of health?

Do you take regular exercise?

Do you drink enough water?

Do you drink caffeine? If yes, please specify the source and how many cups per day

I hereby declare that I have answered the consultation fully and I have not withheld any information that may affect the outcome of the treatment. I know of no reason why I cannot undertake the treatment. It is my responsibility to notify the therapist of any medical changes that may affect any treatment either now or in the future.
I hereby authorize Laura Gil to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist.
The personal information you provided will be securely saved to meet GDPR regulations and will only be kept and used by Laura Gil for insurance purposes as well as to help plan safe and effective treatments. The personal information enclosed during your treatments is strictly confidential and will not be shared with any third parties without your prior consent.
I understand that the treatments I am receiving are complementary therapies and are not a substitute for medical care. I understand that practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional.
If you experience any medical condition and have not seen your doctor yet, I recommend you to do so today.

Consentment

Disclaimer & Consent- please tick the boxes

Name & signature of patient/legally responsible person

Date Signed

Date

Client Consultation Form

Personal Information

Emergency Contact

Medical history

Lifestyle

Disclaimer / Consent