Blueberry Holistics BioKinesiology Consultation Form

New Client Consultation Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Date of Consultation

DayMonthYear
Date
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Address Line 1

Address Line 2
Address

Address Line 3

County
E-mail*
example@example.com
Date of Birth

DayMonthYear
Ages of Children (if any)
Occupation
Doctors Name

First NameLast Name
Next of Kin in case of emergency*
Next of Kin Phone Number

Area CodePhone Number
Health Information
Are you taking any medications
Do you have allergies
Any recent injuries
Are you taking any supplements?
If you answered yes to the above questions, explain further below and list what you are currently taking
Female Question. Are you currently pregnant or breastfeeding?

PregnantBreastfeedingNo
Please indicate if any of the following apply to you.

CancerDiabetesHigh/Low Blood PressureCirculatory problemsUnder Active ThyroidOver Active ThyroidKidney DysfunctionHeart Attack/Heart DiseaseStrokeBlood Clots/Thrombosis/Embolism/HaemorrhageBack/neck problemsArthritisInflammationJoint ReplacementNeuropathy/NumbnessFibromyalgiaSprains/StrainsHeadaches/migrainesDepressionAnxietyStressDigestive Problems/IBSDo you work at a computer?Poor Sleep PatternOperationsRecent InjuriesAny other conditions
If you have ticked any of the above, please explain further OR if your condition is not listed here please explain further below
How do you rate your sleep?

1

2

3

4

5

1 is Bad, 5 is Good
Stess levels?

1

2

3

4

5

1 is Bad, 5 is Good
Do you smoke?

YesNo
How many per day?
Do you drink alcohol?

YesNo
How many times per week?
What is your diet like?

HealthyCould be betterNot good
Give details of what you typically eat for Breakfast, Lunch, Dinner, Snacks?
How much tea and coffee do you drink on a daily basis?
How much plain water do you drink on a daily basis?
Do you exercise? If Yes, then what exercise do you do and how often
How do you relax? i.e. watch TV, read a book, meditate, sleep
Please indicate if you experience any of the following digestive issues:

RefluxBloatingCrampingGasDiarrhoeaConstipation
If any of the following questions apply to you please give details below: Do you have difficulty getting to sleep? How many hours sleep do you get a night undisturbed? If sleep is broken what time of night do you wake? Do you sweat in sleep? Do you grind your teeth? Do you snore?
If any of the following questions apply to you please give details below: Do you wake tired in the morning? Does energy go up and down? Is your energy constantly low/high?
Reason for Visit
What would you like to achieve from your appointment? E.g. Improve gut health, skin health, Immune system, hormone health, energy levels, emotional health etc.
How long have symptoms existed? When are they worse/better. What was initial cause of them if know?
If you have a specific concern, when did it first occur? Describe any stress occurring at the time of the onset
Frequency of pain or concern - please select the most accurate

ConstantOff/OnAt RestWith ActivityNot ApplicableOther
Is this condition interfering with

SleepWorkRelationshipsNot Applicable
Please select any areas of pain that may apply to you from the options below
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movements
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over head
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strength
Mid-Back

Mid- back painPain with breathingOther
Lower Back

Low back painPinched nerve in low backPain up/down low backPain across low back
Hips

Pain in buttocksPain on side of hipPain deep in hip jointPain on sit boneDiagnosed arthritis
Legs and Feet

Pain down RIGHT legPain down LEFT legLeg crampsNumbness in RIGHT footNumbness in LEFT footNumbness in toesCramps in RIGHT footCramps in LEFT footSwollen LEFT footPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Sign up to the Blueberry Holistics newsletter*

YesNo
Client Agreement

Client Agreement: I understand that, Caitríona does not diagnose illness, disease, any physical or mental disorder, nor does she prescribe medical treatment, pharmaceuticals, or perform joint mobilisation. I acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive BioKinesiology as a form of therapy. I have stated my current medical conditions, and will update Caitríona of any changes in my health status. Recommended supplements should only be taken for 4 weeks unless otherwise advised. Check all supplements with your pharmacist if you are taking medication. If you experience any unexpected side effects, please stop taking the supplements. I consent to the processing of my personal data by Blueberry Holistics in accordance with General Data Protection Regulation 2018, solely for the purpose of providing me with a BioKinesiology treatment and any further consultation's that I may have. The personal data may be retained by Blueberry Holistics for seven years from the date of last consultation. I understand it will not be disclosed to any third parties and I may request a copy of it at any time. By my electronic signature below, I agree to the BioKinesiology policy and client agreement above.
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date*

DayMonthYear
Date
Thank you for providing this information, please be reassured that it will be treated with the greatest confidence, and will only be used in helping you to achieve your goal
Other Comments: Please use this space to give any further relevant information that you feel would be beneficial for me to know prior to your treatment.
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