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.
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.
Do you smoke/Vape and how much?*
Alcohol consumption per week*
Phone/tablet, computer and T.V.
Do you eat a healthy well balanced diet?
Do you take any supplements
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?*
Have you had a recent blood pressure test?*
Have you visited the GP in the last 6 months?*
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.
If you answered yes to any of the questions above, please supply additional information.
If you answered yes to any of the questions above, please supply additional information.
If you answered yes to any of the questions above, please supply additional information.
If you answered yes to any of the questions above, please supply additional information.
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.
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