Bowen Consultation Form
Dorset Bowen
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
What is your occupation?
What is your gender?
Please Select
Male
Female
Your GP's name and address
*
How often do you see the GP?
Family History - Diabetes, Epilepsy, Heart Disease, cancer in IMMEDIATE Family
*
Current medication
*
If you have children, please select the number
*
How long ago did you have children?
Have you had any accidents or major illnesses? (Include all, even from an early age)
*
Have you ever in your life had any operations - includes cosmetic surgery? Please list all & ages
*
What is your reason for coming - pain, allergies, skin complaints, digestive issues. Please fill in with detail
*
When did you notice the problem/pain start?
*
What type of pain is it you are suffering with? Is it a stabbing pain, a dull ache?
*
Describe your pain TODAY with 1 being the worst and 10 being the best
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
What are your current stress levels, from 1 being the worst and 10 being the best
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
Do you have any skin problems (Eczema, psoriasis)
*
Do you have any allergies (hayfever)
*
Could you be pregnant
*
Could you be suffering from the Menopause?
What Menopausal Symptoms do you have?
Do you do any Sport or Exercise regularly?
Have you had your wisdom teeth/any teeth removed
*
Do you grind you teeth or snore
*
Are you being treated by another therapist for any problems
Does pain or your ailment keep you awake at night
How is this affecting your day to day life?
What is your sleep pattern like
Do you smoke?
*
Describe your diet - Ready meals, homemade from scratch, take aways, sweets & chocolate.
Do you suffer with any of the following?
Please Give details if any of the above has been ticked
Signature
Submit
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