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Consultation Form Essential Feeling
Please complete all of the questions below and click the enter button at the bottom once complete.
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Email
*
Your email
Full name
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Your answer
Date of birth
MM
/
DD
/
YYYY
Home address
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Your answer
Current age
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Your answer
Contact number
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Your answer
Occupation
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Your answer
GP/ Specialist. If post plastic surgery massage, pls give surgeon's full details and practice.
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Your answer
GP/ Specialist address. If post plastic surgery massage pls give surgeon's address.
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Your answer
Plastic surgeon's email address (NB we need this for your notes)
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Your answer
Do you require your doctor's consent?
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Yes
No
Last visit to doctor/ specialist.
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Your answer
Any current medication?
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Your answer
Children
Your answer
Family dependents
Your answer
Next of kin name
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Your answer
Next of kin contact number
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Your answer
Please note anything below which is relevant.
Pregnancy
Are you trying to get pregnant?
Cardiovascular condition e.g.thrombosis, phlebitis, hypertension, heart condition, 3 months after heart attack/ high or low blood pressure/ 1 month after stroke
Circulation issues/ cold hands or feet
Hemophilia
Medical Oedema
Osteoporosis
Arthritis
Condition treated by GP or other complimentary practitioner
Spondilytus
Nervous/ psychotic condition
Epilepsy
Dysfunction of the nervous system e.g. muscular sclerosis, motor neurone, parkinson's
Diabetes
Asthma/ chest issues
Bells Palsy
Trapped/ pinched nerve/ sciatica/ inflamed nerve
Postural deformities
Spastic conditions
Kidney infections
Undiagnosed pain
Whiplash/ slipped disc
Acute rheumatism
Osteomalaci & rickets
Fever
Contagious/ infectious diseases or infestations/ringworm/ scabies/ impetigo/shingles/ cold sores/ veruca/ warts
Diarrhoea/ vomiting
Severe/ sudden headache
Severe heamophilia
Contagious skin diseases/ athletes foot/ fungal infections
Undiagnosed lumps/ bumps/ cuts/ abrasions/ localised swelling/ bruises/ sunburn
Inflammation -- any 'itis' e.g. tendinitis
Varicose veins
Scar tissue (2 years major/ 6 months minor)
Haematoma
Cirrhosis of liver/ kidney problems
Hernia/ gastric ulcers/ gall stones
Fractures within 3 months
Conditions affecting the neck/muscular or skeletal issue
Prolapsed uterus
Acute injuries/ bursitis/ arthritis
Headaches/ stress/ tension/ irregular periods/ PMT/ PCOS/ Endometriosis
Aches/pain/ stiff joints/ back/
Digestive problems/ Constipation/ Bloating/ Fluid retention.
Hormonal implants/ HRT/ Menopause/ Migraines
Gynaecological problems
Prone to infections/ immune system
Cancer
Skin allergies/ dermatitis/ Eczema etc
Recent surgery inc plastic surgery,pls detail below
If you ticked any of the above, please explain
Your answer
What is your ability to relax?
Poor
1
2
3
4
5
Excellent
Clear selection
What are your sleep patterns?
Poor
1
2
3
4
5
Excellent
Clear selection
How many hours sleep do you get on average?
Choose
Less than 5
5 - 6
6 - 8
8+
How many hours do you see natural light at work?
Choose
None
A few
All day
How many hours do you sit in front of a computer?
Choose
None
A few
All day 8+
Do you eat regular meals?
Yes
No
Maybe
Clear selection
Do you eat in a hurry?
Yes
No
Maybe
Clear selection
Please note any vitamin supplements you are taking
Your answer
How much water do you consume a day?
Your answer
Is your skin...?
Oily
Combination
Dry
Clear selection
Stress level at home
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Low
1
2
3
4
5
Excessive
Stress level at work
Low
1
2
3
4
5
Excessive
Clear selection
Any other comments?
Your answer
How did you hear about us?
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Google
Facebook
Instagram
Doctor/ Nurse
Recommendation
Other:
Please only return this document if you have read this carefully and are in agreement. "I confirm that I have understood the treatment that I am willing to proceed without confirmation from my own GP or consultant." It is your responsibility and not that of the therapist to consult your GP or consultant including any concern you may have around Covid-19. I hereby indemnify the therapist against any adverse reaction sustained as a result of the session.
I also confirm, I have read the privacy policy and terms and conditions and am happy to proceed.
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Yes I agree
No, I don't agree. Please cancel my appointment.
For absolute clarity I understand any photos or videos may be used online but will only be done with your privacy protected. Faces and distinguishing marks such as tattoos will be blanked out unless we receive your express permission.
*
Yes I agree I understand this is important for a small business nowadays
No I'd prefer you don't use anything. Your therapist won't think any worse of you for it.
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