Client Consultation Form
Client Consultation FormConsultation form maybe required for some treatments.Get a head start and save time at your appointment and complete yours now.______________________________________________Client Consultation Form - Private & Confiential* - Please answer the mandatory questions.
•Client Ref#:
•Client Name: *
*Address: *
•D.O.B: *
•Tel/Mob#: *
•Email: *
•Status:
•Occupation: *
•Transportation:
•Children
•Lifestyle: Please include Typical *
•B/Fast
•Lunch
•Dinner
•Snacks
•Beverages -
•Water Amount p/day:
•Tea Amount p/day:
•Coffee Amount p/day:
•Herbal Tea Amount p/day:
•Alcohol Amount p/day:
•Soda Amount p/day: p/wk: p/mth
•Chocolate Amount p/day
•Supplements State:
•Dietary Requirements State:
•Allergies * State:
•Regularity (toilet)
•Smoker * No Yes Amount p/day:
•Exercise *
•Hobbies *
•Relaxation *
•Sleep Patterns *
•Energy (1-10) *
•Stress (1-10) *
•Complementary Therapies:
•
•G.P.'s Name: *
•Address: *
•Medical History: *
•Hypertension/Hypotension
•Asthma
•Diabetes
•Thrombosis
•Epilepsy
•Dysfunction of Nervous System
•Severe Bruising
•Swellings
•Recent Operations
•Sprains
•Warts
•Heart Disease
•Crones Disease
•Cancer
•History of Embolism
•Skin Disorders
•Recent Haemorrhage
•Cuts or Abrasion
•Fractures
•Scar Tissue
•Verruca
•Heartburn
•Eczema/Psoriasis
•Indigestion
•Flatulence
Presentation Condition:
Definition:
Cause:
Symptoms (if any):
Orthodox treatment (medication):
Complementary Treatment:
Treatment Plan -Aftercare -Homecare -
Client signature ......................................................Therapist signature ..................................................<
Date ...................
Please copy and paste completed form to email (if available) and send to geeoz5@talktalk.net.
If email is not an option, please copy and paste completed form to document, print sign and bring along to your appointment.
Dr/G.P's Consent Form
GeeZone - Massage, Health & Beauty Therapies
07931 100 093 / 07812 967 102 / 07706 569 600 or Email: geeoz5@talktalk.net