JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Health Consultation form
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
Your answer
Email
*
Your answer
Address
*
Your answer
Phone
*
Your answer
Date of Birth
*
Your answer
Where did you hear of Holistic Treats
Your answer
Do you have any muscular, joint or skeletal conditions or problems?
*
Your answer
Do you have circulation problems, incl. heart conditions, high/ low blood pressure?
*
Your answer
Do you have any respiratory problems including coughs, colds or asthma?
*
Your answer
Do you have digestive complaints?
Your answer
Do you experience headaches or migraines?
*
Your answer
Do you have any allergies?
*
Your answer
Do you have a contagious condition incl. impetigo, cold sores, verrucae, warts, flu, HIV?
*
Your answer
Women: Do you have menstrual/ menopausal problems, could you be/ are you pregnant?
Your answer
Have you had any injuries or operations in the last 3 months?
*
Your answer
Are you receiving or awaiting any medical treatment? (A doctor’s referral letter may be needed)…
*
Your answer
Are there any other mental, physical or emotional health issues?
*
Your answer
Is there a specific reason for your visit?
*
Your answer
*
I confirm I have read the GDPR policy:
http://holistic-treats.com/gdpr-policy/
Required
*
I confirm I have read the Covid19 Information page:
http://holistic-treats.com/covid19-information/
Required
*
I confirm I have completed the Covid19 questionnaire and declaration:
https://forms.gle/uo4gYqUzHbzWHQa67
Required
Sign and Date
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
