Name           :  
Address        :  
Phone          :  
E.mail         :   
Date of birth :   dd mm yr
Height          :   in cms
Weight         :   in kgs
Occupation  :      

Please answer as thoroughly as possible :

What do you want from your treatment?

How would you describe your general state of health?

Do you have any particular problem at the moment?

How would you describe your diet?

On a stress scale of 1(low) to 10(high) where do you fit?

Are you undergoing any other form of treatment / therapy?

Are you taking any medication at the moment?

Do you often get coughs, colds or sore throats?

What is your skin type / hair type (oily, dry) ?

Do you smoke, chew tobacco or consume alcohol? If yes, how frequently?

Do you or does anyone in your immediate family have any history or current experience of :

Migranes  Heart problems High blood pressure Low blood pressure
Diabetes   Lung problems Kidney problems      Varicose veins        
Epilepsy    Allergies           Thrombosis             
Ovarian  Growth / Cancer        Uterine  Growth / Cancer        

Give brief details :

Do you ever get :
Insomnia Backache                  Bronchitis Chill blains   Heartburn
Arthritis   Cold hands & feet      Eczema    Constipation Ulcers
Asthma   Other skin problems   Period pains

Give brief details :

Is there any further information you would like to give us ?

Declaration: I agree to inform the therapist of any condition which may arise during my course of treatment which has not been covered above.
Yes       No