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Dalesway Therapies - Confidential Client record
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* Indicates required question
Name:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Telephone Number
*
Your answer
Email (if happy to share)
*
Your answer
Name of GP & practice
*
Your answer
Have you had and recent visits to GP, hospital or complementary therapists
*
Yes
No
If you answered yes please give details
Your answer
Primary Concern
Origin & timescale
*
Your answer
Current level of pain & description
*
Your answer
Other issues including stress levels
*
Your answer
Previous Medical History
Please give details if any are relevant. If not relevant please state N/A
Accidents
*
Your answer
Fractures
*
Your answer
Surgery
*
Your answer
Major illnesses
*
Your answer
Medication
*
Your answer
Allergies
*
Your answer
Pregnancy and childbirth
*
Your answer
Exercise - type & frequency
*
Your answer
Client Consent
By ticking this box I agree that the above info is correct at the time of writing and to the best of my knowledge.I acknowledge that I understand and agree to the treatment as advised by my therapist.
*
I agree
Required
To be signed at first appointment
Client Signature
Your answer
Therapist Signature
Your answer
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