Client Consultation Form - Reiki for you
Please fill out this form at your convenience before your appointment with Nathan.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
Town/City
County
Postal Code
Profession
*
Mobile number
*
Home phone
Date of your appointment
Time of your appointment
Hour Minutes
AM
PM
AM/PM Option
Age
*
Gender
*
GP Surgery Address
*
Practice Name
Street Address
Town/City
County
Postal Code
Date of last visit to the doctor
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Client Profile
Medical Contra-indications
Are you pregnant?
*
Yes
No
How many weeks?
*
0-12
2nd trimester
3rd trimester
Contra-indication Restrictions
Do you have any allergies?
*
Yes
No
Physical (select which apply)
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Pain
Swelling
Stiffness
Lack of energy
Disturbed sleep
Skin conditions
Nausea
Constipation
Diarrhorrea
Other
None
On a scale of 1-10 (1 being no pain, 10 being unbearable) where would you place your pain on average? And what type of pain is it? E.g. stabbing, constant...
How many hours of sleep do you get a night on average?
Emotional/mental (select which apply)
*
Anxiety
Stress
Mood swings
Depression
Irritability
Grief
Confusion
Anger
Addiction
Other
None
On a scale of 1-10 (1 being none, 10 being unbearable) where would you place your anxiety on average?
On a scale of 1-10 (1 being none, 10 being unbearable) where would you place your depression on average?
Spiritual (select all that apply)
*
Disconnection
Loneliness
Questioning beliefs
Other
None
If you selected any of the conditions above, please give details for each conditions e.g. how long you have had it and how it affects you.
Concent
Please read the information and sign below to give your informed consent to receive Reiki. Please read carefully and only sign if you are in full agreement with its contents.
I [your name below] confirm that I have understood the treatment that I am to receive, give my full concent to receive this treatment, and confirm that I am willing to proceed without confirmation from my own GP or Consultant. I hereby indemnify the therapist Nathan Krifdom (Buddha Hand Holistics) against any adverse reaction sustained as a result of the treatment. I understand that it is my responsibility and not that of the therapist to consult with my doctor regarding suitability of receiving this treatment, if I so wish to. I have read and agree to the privacy policy and disclaimer on buddhahandholistics.uk. I am happy for this, and future information about me to be kept in accordance with the Data Protection Act 1998 in hard or digital formats.
*
Name
*
First Name
Last Name
Today's date
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Medical History
Please select all that apply
Muscular/skeletal problems
*
Back
Aches/pains
Stiff joints
Headaches
None
Digestive problems
*
Constipation
Bloating
Liver/gall bladder
Stomach
None
Circulation
*
Heart condition
Blood pressure issues
Fluid retention
Tired legs
Varicose veins
Cellulite
Kidney problems
Cold hands and feet
None
Gynaecological
*
Irregular periods
P.M.T.
Menopause
H.R.T.
Pill
Coil
None
Nervous system
*
Migraine
Tension
Stress
Depression
None
Respiratory
*
Allergies
Hay fever
Asthma
None
Skin conditions
*
Dermatitis
Acne
Eczema
Psoriasis
Skin cancer
None
Skin type
*
Dry
Oily
Combination
Sensitive
Dehydrated
Immune system - select which you are prone to
*
Infections
Colds
Sore throats
Chest issues
Sinus issues
None
Have you taken in the past, or currently taking any medication? If so, please give details.
Are you taking any herbal remedies? If so, please give details.
Any other health conditions or things your therapist should know?
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Lifestyle
Please select all that apply
What methods do you use to relax?
*
What is your sleep pattern
*
Regular
Mixed
Irregular
How would you rate your sleep?
*
Good
Moderate
Poor
On average, how many hours of sleep a night?
*
What is your work environment?
*
Do you work at a computer?
*
Yes
No
Occasionally
If yes/occasionally, how many hours at a time on average?
Do you smoke/vape?
*
Yes
No
Used to but quit
If yes, how often?
Do you drink alcohol?
*
Yes
No
If yes, how many units per week?
Do you exercise?
*
No
Occasionally
Irregularly
Regularly
What type/s of exercise do you do?
Stress level at work
*
Please Select
1 (no stress)
2
3
4
5
6
7
8
9
10 (heavily stressed)
Stress level at home
*
Please Select
1 (no stress)
2
3
4
5
6
7
8
9
10 (heavily stressed)
Reasons for stress?
Why would you like Reiki?
*
Are you happy with hands on Reiki, or would you like hands off? (We can discuss this during your session if you wish) N/A if you are having a distance session
*
YOU'RE DONE!
Thank you so much for taking the time to fill out this form. See you at your appointment!
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