General Consultation Form OAW

General Online Consultation Form

Ocean Air Wellness
Thank you for inviting me to be part of your heath and wellness journey, I look forward to supporting you. Please complete this form as honestly as you can, if there is anything you don't feel you can write here, please feel free to let me know later as you feel more comfortable with me. Some of the questions may seem a bit odd, but they all help me to understand you as a whole and as to how best I can support you.

The more information you can give the better, these questions offer a framework, but if you have a long complex medical history, you may wish to type it out and send me that as a separate file, which you can upload at the bottom of this form. Sometimes just sitting down to write your story so far, realising and acknowledging how far you have come can be a very helpful process in itself.

I look forward to receiving your form.

Sending love and light.

Nari x
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
GP Name and Surgery *
If you work, what do you do?*
Any medical conditions?*
Do you suffer from any of the following conditions? If you select any, please provide further details in the next question.

EpilepsyThrombosisMigraineDiabetesKidney or Bladder problemsHeart or chest problemsDigestive or bowel problemsAsthmaBack problemsLow or High Blood pressureVaricose veinsSkin ProblemsCancerArthritisAnxietyDepression
Please give more details about any issues mentioned above, including when you have suffered, for how long, what helps, what makes things worse etc.
Are you taking any prescribed medication? If so give details.
Are you taking any herbal supplements or vitamins? If so give details
Do you have any allergies?*
How are your stress and anxiety levels?*
How are your energy levels?*
How are your sleep patterns, do you get to sleep easily and stay asleep, or do you wake in the night? what times do you wake in the night?*
Any past surgical operations or serious illnesses?*
Have you tried any other complementary therapies or do you receive treatments from any other practitioners?*
Are you currently pregnant? Have you ever had any pregnancies, miscarriages or terminations? Please give details or State N/A*
How are you hoping I can help you? Reason for booking?
What life changes would you like to achieve in the next 6 months?*
Is there anything else you wish to share with me, or think I should know?*

Treatment booked
Please select your preferred treatment/s types from the choices below:
Type a question

MassageTraditional Chinese Medicine/AcupunctureHijama therapyLifestyle CoachingOther
Would you like to sign up to our Newsletter to receive any upcoming offers/discounts/information in relation to your Wellbeing?

YesNoMaybe
Can I ask how you found me, or who recommended you?
I confirm that all of the above information is accurate and true to the best of my knowledge. I declare that to the best of my knowledge I am not allergic to any of the ingredients in the treatment creams or oils. Minor bleeding or bruising can occur from Acupuncture/Hijama therapies. Signature of this form implies acceptance of all treatments. Appointments cancelled with under 24 hours notice will be charged 50% of the booked treatment cost. Please ask if you require a receipt.
Signature (Parent or Guardian if for a child)*

Clear
Upload any files relevant to you or your medical history.

Cancelof
Should be Empty:

General Online Consultation Form