RM Client consultation form - Reiki-infused Massage

  • Client Consultation Form - Reiki-infused Massage

    Please fill out this form at your convenience before your appointment with Nathan.

  • Client Profile

  • Medical Contra-indications

  • Are you pregnant?*
  • How many weeks?*

  • Massage cannot be given between 0-12 weeks due to risk of miscarriage

    Please contact Nathan for more info
  • Please select all that apply to you*

  • Contra-indication Restrictions

  • Please select all that you are experiencing*
  • Do you have any allergies?*

  • Consent

    Please read the information and sign below to give your informed consent to receive Reiki-infused Massage. 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.

  • Medical History

    Please select all that apply
  • Muscular/skeletal problems*
  • Digestive problems*
  • Circulation*
  • Gynaecological*
  • Nervous system*
  • Respiratory*
  • Skin conditions*
  • Skin type*
  • Immune system - select which you are prone to*
  • Emotional/mental*
  • Spiritual*

  • Lifestyle

    Please select all that apply
  • In general, how is your ability to relax?*
  • What is your sleep pattern*
  • How would you rate your sleep?*
  • Do you have natural daylight while at work or the place you spend most of your day?*
  • Do you work at a computer?*
  • Do you smoke/vape?*
  • Do you drink alcohol?*
  • Do you exercise?*

  • Diet

  • Which meals do you eat regularly?*
  • Do you normally eat in a hurry?*
  • Do you take any food/vitamin supplements?*

  • _________

    How many portions of each of these items does your diet contain per day?

  • How many food items per day on average contain:

  • _________

    How many units of these drinks do you consume per day?

  • 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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