CONSULTATION FORM

CONSULTATION FORM

please fill in fully, this form is confidential
guru holistic therapy and training rooms
Name

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Postal Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of birth

DayMonthYear
Date
What is your occupation?*
Please take time to fill in your medical details:
Blood-clotting issues: have you had any of the following?*

ThrombosisEmbolismAneuryismPhlebitisBleeding disorderNo
Blood-clotting: Have you had any of the following?

thrombosisembolismaneuryismphlebitisbleeding disorderno
Have you had a recent operation or injury?

yesnoopen cuts/woundsrecent hemorrhage
Have you had a recent operation or injury?*

YesNoOpen cuts/wounds/scarsRecent haemorrhage
Please give details
Do you have a skin disorder or infection*

YesNo
Please give details
What is your skin type?

NormalDryOilySensitive/reactiveBruises easily
Please indicate skin type:

normaldryoilysensitive/reactivebruise easily
Do you have any nervous system issues?*

Sinus issuesMigraine/headachesAnxietyStressDepressionMental health issues, e.g bipoloarMS/ParkinsonsOtherNo
Please give details
Do you have any nervous system issues?

sinus issuesmigraineanxietystressdepressionmental issues eg biopolarMS, parkinsonsNoneOther
Have you had a recent pregnancy or are you pregnant?*

N/ANoYes, pregnantPost natalBreastfeedingMiscarriageTrying to conceive
Please give details
Any details are helpful
Have you had a recent pregnancy or are you pregnant?

noyes pregnantpost natalbreastfeedingtrying to conceiveN/A
Do you have high or low blood pressure?*

High blood pressureLow blood pressureNormal blood pressureHeart condition
Give details of your heart condition?
Blood pressure medication, angina, etc.
Do you have any form of epilepsy?*

YesNo
Please give details
Do you have any form of diabetes?*

Yes type 1Yes type 2No
Please give details
Skeletal: Do you have any of the following?*

Rheumatism/ArthritisOesteoporosisSciolosis/spondylitisVaricose veinsNone of the aboveOther
Skeletal: Do you have any of the following?

rheumatismarthritisoesteoporosisscoliosisspondylitisvaricose veinsothernone of the above
Please give details
Do you have claustrophobia?*

YesNo
Please give details
Do you have any allergies?*

YesMild intolerancesNo
Please list any allergies, eg metal
Do you have or had cancer*

YesNo
If yes, please let us know more
Do you have a pacemaker, implants or any metal implants?*

YesNo
Please give details
Have you had a steroid injection*

YesNo
Please state when you had it
Do you have any contagious diseases?*

YesNo
Please state what it is:
Blood: Do you have any of the following?*

HIVHepatitisNoOther
Please fill in details
Covid status*

Tested positiveCaring for someone that has tested positiveNo covid
Do you have any medical issues?*

YesNo
Please give details if answered yes
Are you taking any medication?*

YesNo
Please list reason for taking it:
laymans terms preferred
Is GP referral required (therapist to fill in)

YesNo
GP Name and address
Are you receiving any other form of Complementary therapy at the moment?

yesno
Regarding above question: Please state business name/therapist name and treatment receiving
ABOUT YOU:
What are your energy levels like at the moment?
What are your energy levels like at the moment?
What are your stress levels like at the moment?
What are your stress levels like at the moment?
Treatment booked today
Therapist booked with today
Any special requirements?
E.g. mobility
Notes:
Anything that you would like to discuss with your therapist?
Parking permit, do you want to tell us your car registration?
We could have your permit ready for you if we know
I am using a gift voucher and the code is:
Please fill in code
Disclaimer:

Disclaimer: I declare that all the information given today is correct and I will inform my therapist as and when any changes occur. I am responsible for my own health and will agree to changes to treatment if appropriate.
I am responsible for my own appointment and will give at least 24 hours notice of cancellation or re-arranging date/time. If 24 hours is not given I know I will lose payment made. If payment has not been made I will pay the invoice sent within 7 days.
Date

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Date
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CONSULTATION FORM

guru holistic therapy and training rooms

Please take time to fill in your medical details: