Repeat Client Record

Repeat Client Record - please complete at least 48 hours before your next 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

Date of Birth

DayMonthYear

Mobile Number*

Email*

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 is the reason for your treatment? (for example, general relaxation, or specific areas of concern)*

Have there been any changes to your health or medical history since your last appointment?*

YesNo

If yes, please give details:

Client Declaration:

I have completed the above questionnaire fully and declared any changes to my health and medical history since my last appointment; as far as I am aware I can continue to undertake massage and reflexology with Bridgnorth Holistic Therapies without adverse effects. Any potential contra-indications highlighted by the information above will be discussed at the time of my appointment. I understand that massage and reflexology are not substitutes for medical examination, diagnosis or treatment. I give my informed consent to proceed.

Signature*

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

Date*

DayMonthYear