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*
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?*

YesNo
If yes, please give details:
Do you have any allergies?*

YesNo
If yes, please give details:
FEMALE CLIENTS ONLY: Are you currently pregnant or breastfeeding?

PregnantBreastfeeding
Please give details of any current or previous pregnancies:
Medical History
Please indicate if any of the following apply:

High or low blood pressureHeart conditionsHistory of thrombosis/embolismCurrent or previous cancerDiabetesEpilepsyFibromyalgiaMajor operationsRecent fractures or sprainsArthritisOsteoporosisBack problemsRecent cuts or abrasionsVaricose veins or phlebitisSwelling or oedemaHeadaches/migrainesDepressionSkin conditionsRecent medical procedures (including botox)Any infectious diseasesCOVID-19 (previous 14 days)Fungal infections (such as atheletes foot)Verrucas
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

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

DayMonthYear
Should be Empty: