Consultation Form Please complete the new client consultation form below before your first appointment with Sam Name * First Name Last Name Email * Phone Number * Address * Date of Birth MM DD YYYY Occupation Doctor's Name and Surgery * Emergency Contact's Name * First Name Last Name Emergency Contact's Number * Reason for Treatment * Relaxation Muscle Tension Specific condition (please give details below) Health Check Please tick any of the following conditions that you have had in the past or present Headaches Significant accident Whiplash TMJ dysfunction (jaw pain) Hearing issues/tinnitus Respiratory problems Heart/blood pressure problems Diabetes Digestive problems Kidney problems Menstrual/menopausal problems Stress Emotional problems Allergies Immune problems Arthritis Cancer Skin conditions Infectious diseases Long covid Please give details on any of the above that you feel may be relevant. Have you ever had surgery? * If yes, please give details below Yes No Are you taking any medication? * If yes, please give details below Yes No How would you describe your stress levels? * Low Medium High How would you describe your energy levels? * Low Medium High Do you sleep well? * Yes No Do you do some form of regular exercise? * If yes, please give details of the type and regularity below Yes No Do you feel the cold or get cold extremities? * Yes No Are you / could you be pregnant? Yes No Are you breastfeeding? Yes No How did you hear about me? * Google search Website Facebook Recommendation Other Declaration * The information that I have provided above is true and correct. I understand that body massage is not a substitute for medical advice and/or treatment. I have read and understood the terms and conditions below. Thank you for completing your consultation form.
