Complementary/Holistic Therapies - Client Consultation Form

Complementary/Holistic Therapies - Client Consultation Form

Health and Medical History. Please complete this health consultation e-form before your appointment. You do not have to share your personal data with us, but if you do not then we cannot offer you a treatment with Luna Beauty & Holistic Therapies. You must fulfil your request for completing a client health form (share your personal information) in order for us to fulfil ours (carry out a treatment).
Please complete this form as honestly as you can do, if there is anything you don't feel you can write here, please feel free to let me know later as you feel more comfortable or please give me a ring.

The more information you can give the better, but if you have a long complex medical history, you may wish to type it out and send me that as a separate file (which you can upload at the bottom of this form). Sometimes just sitting down to write your story so far, realising and acknowledging how far you have come can be very helpful in itself.
Name

First NameLast Name
DOB

DayMonthYear
Date of Birth - if you do not wish to disclose, please leave blank
Email
I give consent to be contacted by email (do not give email if you do not wish to be contacted by email)
Landline Phone Number
Please enter a valid landline phone number - if you have. I give consent to contact by telephone.
Mobile Phone Number
Please enter a valid mobile phone number - if you have. I give consent to contact by telephone and SMS.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Name blanks Name of Surgery/Medical Practiceblank

Medical History - please tick all that are relevant
Please give more details about any issues mentioned above, including when you have suffered, for how long, what helps, what makes things worse etc.
Certain medical conditions may require consent from the medical professional responsible for your health including GP/Consultant/Nurse.
Any other serious illnesses/health details not listed in the list above
Certain medical conditions may require consent from the medical professional responsible for your health including GP/Consultant/Nurse.
Details of any operations (and dates)
Relevant operations especially spinal or neck surgeries. If you have had recent surgery this may be contra-indicated, your Therapist will discuss this with you.
Are you taking any prescribed medication? If so give details
If you do not know the exact pharmaceutical name of the medication - please state the condition the medication is taken for.
Are you taking any herbal supplements or vitamins? If so give details
Pregnancy clients - tick all that are relevant (otherwise ignore)

History of miscarriageHistory of bleedingHistory of Thrombosis/EmbolismHistory of Fertility TreatmentOther
Pregnancy clients (cont) Please state how many weeks pregnant you? Please give further details if any of the above boxes are ticked
Do you have any allergies?
How are your stress and anxiety levels?
You do not have to answer this question - but it is helpful for your Therapist to know
How are your energy levels (times of slumps)
You do not have to answer this question - but it is helpful for your Therapist to know
How are your sleep patterns, do you get to sleep easily and stay asleep, or do you wake in the night?
You do not have to answer this question - but it is helpful for your Therapist to know
If you work, what do you do?
You do not have to answer this question - but it is helpful for your Therapist to know
How would you describe your nutrition?
This is to help understand your lifestyle and health
Do you exercise regularly? *
This is to understand your lifestyle and activity levels
Are you a smoker?
You do not have to answer this question - but it is helpful for your Therapist to know
Do you drink alcohol?
You do not have to answer this question - but it is helpful for your Therapist to know
How are you hoping I can help you? Your reasons and expectations of having a treatment
Eg:- pain relief, relaxation, stress and anxiety relief, self-care, where you hope to be in 3 to 6 months
Have you tried any other complementary and holistic therapies or do you receive treatments from any other practitioners (such as physio, chiropractor etc)?
You do not have to answer this question - but it is helpful for your Therapist to know
Is there anything else you wish to share with me, or think I should know?
You do not have to answer this question - but it is helpful for your Therapist to know
How did you hear about Luna Beauty & Holistic Therapies - word of mouth (can I ask who recommended you here), facebook, instagram, website, any other way
You do not have to answer this question - but it is helpful for your Therapist to know
CLIENT DISCLAIMER :- I understand all types and forms of complementary and holistic therapies are not a replacement for a proper diagnosis or treatment by a qualified medical practitioner. I accept that the therapist can guarantee no specific results. I accept full responsibility for my own well-being and for reporting my physical and psychological health to my own GP/Consultant/Nurse. I confirm that the above is a true statement. I have read and understood the disclaimer. I am aged 16+.

If aged below 16 - parent or guardian to sign this form below. Certain treatments are not possible below age 16, this will be discussed with you.
COVID19 - I agree to tell the Therapist if I fall ill with Covid-19 either
before or after my therapy appointment, with the understanding that the therapist may cancel/postpone my treatment if I contract Covid-19. Luna Beauty & Holistic Therapies has a COVID19 Policy which is available on the website www.lunaholistictherapies.co.uk.

I consent to my treatment records and the information on this form to be kept securely under GDPR regulations.
Signature

Clear
Today's date

DayMonthYear
Date
Time
Upload any files relevant to your medical history

Cancelof
Luna Beauty & Holistic Therapies needs all the details above in order to ensure it is safe to provide a therapy treatment you may ask for and for insurance purposes. Your client health form will be treated with the utmost confidentiality and security. Paper copies of personal information is stored in a locked file. Any email correspondence, SMS or Facebook messages containing personal data are password protected and secure. Your information will be stored for 7 years after the date of your last treatment or for 7 years after you have reached the age of 18, if you are/were under 18 when your treatment took place. The lawful basis for processing this personal information is contract; this means we have a legal reason to ask you for your data because it is needed for contractual reasons. e-Newsletters are usually sent 3 or 4 times each year and we use a third party provider MailChimp to deliver emails. Individuals can unsubscribe at any time from e-Newsletters. Full details available in Luna Beauty & Holistic Therapies Privacy Policy – July 2020 (published on website www.lunaholistictherapies.co.uk)

COVID19 – If situation of a COVID19 infection arises, we will inform Test and Trace of contact details.
Thank you for completing this form.

Your co-operation and custom is greatly appreciated at this time.

We are taking every precaution over and above Government Guidance for Close Contact Services to ensure Luna Beauty & Holistic Therapies is a Covid19 secure salon.
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