K's Holistic Therapy Health Consultation Form

K's Holistic Therapy Health Consultation Form
Name:*

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postcode:
Landline Number:

Area CodePhone Number
Mobile Number:
Please enter a valid phone number.
Email:*
example@example.com
Date of Birth:

DayMonthYear
Date
No. of Children:
Occupation(s):
GP Name:
GP Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Telephone Number:

Area CodePhone Number
Last Visit To GP:

DayMonthYear
Date
State the reason as to your last visit to the GP and/or any other Practitioner(s):
Health Disorder/Conditions/Symptoms - Please select all that apply:*

PregnantPostpartumNeck PainBack PainMigraine/HeadachesHigh Blood PressureBruise EasilyDiabetesSeizuresKnee/Leg PainMetal ImplantsFibromyalgiaUsed Retin -A within the past 10 days?CancerEmotional ProblemsRespiratory ConditionsInsomniaContagious Skin ConditionRecent PregnancyVaricose VeinsAllergiesPoor CirculationKidney/BladderArthritis/RheumatismMenstruation ProblemsInfertilityHormonal ProblemsFluid RetentionCelluliteOverweightHigh CholesterolHeart ConditionsThyroidThombosis/PhlebitisDigestive ProblemsStressEmotional ProblemsDepressionOther
Please list any Allergies and Sensitivities you may have:*
List any medications, supplements, or herbal remedies you currently take:
Please list any Accidents/Injuries/Operations in the last 3 years till recent:*
Select Massage Treatment(s):

SwedishAromatheraphyHot StoneIndian HeadPregnancyReflexologyDeep TissueFacials
Preferred Massage Pressure?

LightMediumFirm
What do you consider your skin type?

NormalOilyMatureDryCombinationAgeingSensitiveAcneOther
What are your specific concerns at this time regarding your skin and are you recieving any medical treatment for it?
What is your daily/night skin care regime?

CleanseExfoliateToneMoisturiseSPFFacial MaskRetinolN/A
What is your goal for this session?
Preferred Pronoun used:

She/Her/HersHe/Him/HisThey/Them/Theirs
How did you hear about K's Holistic Therapy?
Please Read Disclaimer/Terms conditions: Once read agree to proceed

I am a fully Qualified, Insured & Experienced Beauty Massage Therapist.

I practice beauty massage and complementary holistic therapies and committed to my professionalism. It's important to mention that I'm not able to diagnose any illness or health condition. My intention is to focus the treatment to your specific needs, aid healing & induce relaxation; thus encouraging the body to regulate and to heal itself. I cannot and will not diagnose any illness or medical, physical or mental condition.

If you have any concerns regarding your health you should consult your GP and request for a note and/or letter consenting to recieving any of the treatments we provide.

A course of treatments is highly recommended for best results, although a one off treatment can be incredibly beneficial for the mind and body.

I look forward to meeting you.

K's Holistic Therapy
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Therapist Signature:*

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