Health Consultation form

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Email *

Name *

Email *

Address *

Phone *

Date of Birth *

Where did you hear of Holistic Treats

Do you have any muscular, joint or skeletal conditions or problems? *

Do you have circulation problems, incl. heart conditions, high/ low blood pressure? *

Do you have any respiratory problems including coughs, colds or asthma? *

Do you have digestive complaints?

Do you experience headaches or migraines? *

Do you have any allergies? *

Do you have a contagious condition incl. impetigo, cold sores, verrucae, warts, flu, HIV? *

Women: Do you have menstrual/ menopausal problems, could you be/ are you pregnant?

Have you had any injuries or operations in the last 3 months? *

Are you receiving or awaiting any medical treatment? (A doctor’s referral letter may be needed)… *

Are there any other mental, physical or emotional health issues? *

Is there a specific reason for your visit? *

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I confirm I have read the Covid19 Information page: http://holistic-treats.com/covid19-information/

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I confirm I have completed the Covid19 questionnaire and declaration: https://forms.gle/uo4gYqUzHbzWHQa67

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Sign and Date *

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