Energy Healing Consultation Form

Energy Healing Consultation Form

In order for me to provide the most beneficial treatment for you, it is necessary to ask the following questions. Please complete this form prior to attending the studio, at least 48hrs prior to your first appointment
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email*
example@example.com
Phone Number*

Area CodePhone Number
Your age range

Under 2020-3030-4040-5050-6060+
Name and contact details of GP/GP surgery (please include address and telephone number)*
Have you had an energy healing treatment before?
What prompted you to make your energy healing appointment? (please provide as much detail as possible, especially if you have experienced a recent event or physical or mental health condition which has led you to seek energy healing)
CONTRAINDICATIONS * Energy healing has no known contraindications or adverse effects and is not known to interfere with any medical care. However, it can be helpful for me to be made aware of any physical or mental health conditions which may impact your session and/or require adaptations (for example, if you are unable to lie flat). Information you provide also helps me to prepare and/or respond accordingly should you experience any symptoms of a pre-existing medical condition whilst in the studio. Please tick the relevant boxes below if you are affected by any of the following:

Cardiovascular conditions (thrombosis, phlebitis, hyper/hypotension, heart conditions)Recent operations (cancer and non-cancer related)Postural deformitiesHaemophiliaDiabetesConditions causing muscular spasticity e.g., cerebral palsyAny medical condition already being treated by a GP or other medical practitionerAsthmaWhiplash/slipped disc/trapped or inflamed nerve/sciaticaMedical oedemaNervous system dysfunction e.g., multiple sclerosis, parkinson's disease, MNDArthritisMental health conditions e.g., psychosis, bipolar, schizophreniaAcute rheumatismEpilepsyCervical spondylitis
Please list any medications, supplements, or herbal remedies you currently take (this information is optional, but may help me to prepare and/or respond accordingly should you experience any adverse reactions/side effects of your medication whilst in the studio)
CONTRAINDICATIONS WHICH MAY IMPACT OR REQUIRE ADAPTATION OF ENERGY HEALING TREATMENT* As above, some conditions may prevent you receiving treatment until your symptoms improve, or require adaptations in order to help you feel more comfortable during your treatment. Please tick the relevant boxes below if you are affected by any of the following:

FeverContagious or infectious diseasesSkin diseases/disordersPregnancyDiarrhoea and/or vomitingRecent fractures (minimum 3 months)Varicose veinsUndiagnosed pain/lumps/bumps/lesionsLocalised swellingConditions affecting the neckCirculation problems e..g., blood pressure, heart palpitations, cold hands/feet, fluid retentionFibromyalgiaAnxiety/depression/low moodSleep problems or sleep disorders
Please list allergies or sensitivities:*
Please list any recent injuries not already highlighted:
What is your stress level right now?

LowAverageSomewhat StressedVery Stressed
DISCLAIMER:

To the best of my knowledge I confirm that the information I have provided is true and I have not withheld any information concerning my health and wellbeing. I will keep Sekhem Massage Therapy updated on my health should there be any changes to the answers given in this form.

I understand that my therapist does not diagnose illness, disease or any other physical or mental health condition. I understand that the energy healing treatment I receive at Sekhem Massage Therapy is intended as a complementary therapy and is not a substitute for medical examination, advice, diagnosis or treatment.
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