Consultation Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Post Code
Postal / Zip Code
Date of Birth
*
/
Day
/
Month
Year
Date
Phone Number
*
Email
*
example@example.com
Sex
*
Female
Male
Non-binary
Other
Current Activity Levels
*
Active
Moderate
Sedentary
GP Practice
Last visit to Doctor
-
Day
-
Month
Year
Date
Occupation
*
Number of Children (If Applicable)
What is the reason for a visit?
Medical history
List of any medications taken
Ability to relax
*
Good
Moderate
Poor
Sleep quality
*
Good
Poor
Do you exercise? If so how many times per week?
*
Do you see natural daylight in your workplace?
*
Yes
No
How many hours a day do you work at a computer?
*
Stress levels at home (10 being highest)
1
2
3
4
5
6
7
8
9
10
Stress levels at work (10 being highest)
1
2
3
4
5
6
7
8
9
10
Emergency contact / Relationship
*
Phone number
*
Disclaimer Form
*
I have stated all my known medical conditions, in confidence, and take it upon myself to keep the Therapist updated on my physical health. I consent to this consultation, assessment and then treatment, which will involve soft tissue techniques.
Client Full Name
*
Signature
*
Date
-
Day
-
Month
Year
Date
Submit
Submit
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