Body Treatment Client Form

Body Treatment Client Form

Dorset Bowen
Your current title?

MrMrsMsMissDrOther
Client's Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Phone Number*

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Do you have children, if so how many?
Medical History. Does anyone in your immediate family suffer with Diabetes, Cancer, Heart Disease or Epilepsy?
Are you taking any medication or supplements?
Do you have any allergies (such as essential oils nut based oils) products?*
Are you currently in any pain, if so please describe where on the body & the type of pain.?
What area do you require treating today?*
Are you suffering from any illness at the moment?*
Are you suffering with stress, anxiety or depression?*
Have you had any Operations in the last 6 months? If so, what were they & when was the date of the operation please.?*
Do you have a condition you feel this treatment will help?*
GP name & Surgery?
Body skin condition

NormalOilyDrySensitiveBruise easilyOther
Do you have any of the following conditions? If yes, please select them:

CancerMetal ImplantsPacemakerDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresHigh/Low blood pressureMigraines/HeadachesPsoriasisEczemaBruise EasilySpinal Cord InjuryImmune DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsDigestive problemsAny current open woundsPMTWater RetentionOther
What are your energy levels like?
If you have answered yes to the above, please give details
Are you pregnant?*

YesNo
Are you breastfeeding?

YesNo
How did you hear about Dorset Bowen?
Client Signature

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