| Personal Details |
| Title | |
| First name | |
| Surname | |
| Date of birth (dd/mm/yyyy) | / / |
| Email address | |
| Address line 1 | |
| Address line 2 | |
| Town/City | |
| County | |
| Post code | |
| Country | |
| Occupation | |
| Telephone | |
| Mobile number | |
| Medical Details (Leave blank if not applicable) |
| Allergies? | |
| Accute Infectious disease? | |
Any potentially fatal/terminal condition?
| |
| Diabetes? | |
| Dysfunction of the nervous system? | |
| Epilepsy? | |
| Heart condition? | |
| High or low blood pressure? | |
| High temperature or fever? | |
| Migraines or headaches? | |
| Recent haemorrhage? | |
| Recent head or neck injury? | |
| Recent surgery? | |
| Recent scar tissue? | |
| Scalp infections? | |
| Severe bruising, open cuts or abrasions? | |
| Skin infections? | |
| Thrombosis/embolism? | |
| Undiagnosed lumps, bumps or swellings? |
|
| Female Clients |
| Is it possible that you may be pregnant? | Yes No |
| Are there any other conditions you have which may affect the proposed treatment? | |
| Are you taking any medication? | |
| Is a GP required? | Yes No |
| Clearence form sent? | Yes No |
| Clearence form recieved? | Yes No |
| Name of Doctor? | |
| Surgery? | |
| Address? | |
| Telephone number? |
|
| Lifestyle |
| Is your general health/immunity: | Good Average Poor |
