Health declaration and consent to treatment

Please fill out the following form prior to initial treatment or first order of any of our bespoke product range.

Personal details

This information is collected incase we need to contact your for any reason refeer you on to another service or healthcare professional. this will also speed up the despencing or any future product orders. This information may also be used in the case of an emergency while you are under our care.

Contact Info

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Date of birth

Day

Month

Year

Gender

Male

Female

Prefer not to say

Emergency contact

First name

Surname

Phone

General Info

Living status

Occupation

Activity Level

Lifestyle

Do you smoke/Vape and how much?

Alcohol consumption per week

Sleep hygiene

Exercise

Screen time per day

Nutrition

Do you eat a healthy well balanced diet?

Yes

No

I'm not sure I would like advice

Fluid intake

Do you take any supplements

Treatment objective

What is the reason for you visit?

How does this affect you day to day physically and mentally?

How often is this a problem for you?

Is there anything that makes it better or worse?

Health and Medical

Have you had a recent blood pressure test?

Yes

No

Have you visited the GP in the last 6 months?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Are you suffering from any of the following medical conditions?

If you answered yes to any of the questions above, please supply additional information.

Allergies

Yes

No

If you answered yes to any of the questions above, please supply additional information.

Family medical history

I confirm that I have disclosed all relevant medical conditions and will inform the therapist of any changes to my health. I understand the therapist cannot be resposible for undisclosed conditions. I acknowledge that the therapist practices within their professional scope and does not diagnose, prescribe or treat medical conditions. results are not guaranteed, and possible side effects will be explained prior to treatment.

Acceptance of the above statment.

In the event of emergency, I give permission for appropreate first aid to be administered and for the emergency services to be contacted if necessary.

By signing bellow, I acknowledge my consent of objective assessment and to receive agreed upon therapy

Initials

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.