Initial Consultation Form

Client Initial Consultation Form - please complete at least 48 hours before your first appointment. If you have any problems completing the form please contact bridgnorthholistictherapies@gmail.com.

All information is held in strictest confidence, and will not be disclosed or shared without obtaining your written consent.

Name

First NameLast Name

Mobile Number

Format: 00000000000.

Email

Occupation

Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry

Date of birth

DayMonthYear

General State of Health

What are your current stress levels?

	1	2	3	4	5

1 is Low, 5 is High

What are your current energy levels?

	1	2	3	4	5

1 is Low, 5 is High

What is the quality of your sleep like?

	1	2	3	4	5

1 is Low, 5 is High

What are you hoping your treatment can help with? (for example, general relaxation, or are there specific areas of concern?)

Are you currently taking any prescribed medication, natural remedies or supplements?

If yes, please give details:

Do you have any allergies?

If yes, please give details:

FEMALE CLIENTS ONLY: Are you currently pregnant or breastfeeding?

Please give details of any current or previous pregnancies:

Medical History

Please indicate if any of the following apply:

If you have ticked any boxes above, please give further details, including when/how long, any treatment you've had, what helps, and what makes things worse

Where did you hear about Bridgnorth Holistic Therapies?

Client Declaration (to be completed by parent/guardian where appropriate):

I have completed the above questionnaire fully and declare the information I have given is complete and true, and as far as I am aware I/my child can undertake massage, reflexology or Gentle Release Therapy with Bridgnorth Holistic Therapies without adverse effects. Any potential contra-indications highlighted by the medical questionnaire above will be discussed at the time of the appointment. I understand that massage, reflexology and Gentle Release techniques are not substitutes for medical examination, diagnosis or treatment. I give my informed consent to proceed.

Signature

Sign using a touchscreen or left click and hold as you sign with your mouse or trackpad.

Date

DayMonthYear