Body Treatment Client Form
Dorset Bowen
Your current title?
Mr
Mrs
Ms
Miss
Dr
Other
Client's Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / 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?
*
Please Select
Abdomen
Arms
Thighs
Buttock area
Face & Neck
Back
2 or more of the above
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
Normal
Oily
Dry
Sensitive
Bruise easily
Other
Do you have any of the following conditions? If yes, please select them:
Cancer
Metal Implants
Pacemaker
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
High/Low blood pressure
Migraines/Headaches
Psoriasis
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Skin Disease
Fibromyalgia
Menopause
Circulation Disorder
Varicose Veins
Digestive problems
Any current open wounds
PMT
Water Retention
Other
What are your energy levels like?
If you have answered yes to the above, please give details
Are you pregnant?
*
Yes
No
Are you breastfeeding?
Yes
No
How did you hear about Dorset Bowen?
Client Signature
Print Form
Submit
Should be Empty: