Holistic Cocoon Consultation Form
First name
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Second name
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Post code
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Telephone number
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Email address
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How did you hear about us?
Do you have a voucher? Please provide the code and security code
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Contraindications
Please tick if you have any of the following details conditions
We will have to contact your GP for consent if you have any of the following details conditions
GP details
NB: ONLY REQUIRED IF you have ticked any of the above conditions
Please indicate your GP's name, surgery and telephone number
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Restrictive Conditions
Do you have any of the following conditions?
Are you currently receiving any treatment for cancer? If so, would you mind sharing some details?
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Have you any loss of movement? If so, would you mind sharing some details?
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Do you take any medication? If so, would you mind sharing some details?
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Do you have any allergies or sensitivities?
Do you have any skin conditions?
What is your skin type?
Are you pregnant? If so how many weeks?
Enter no. of weeks in the text box marked Other
Have you any areas of discomfort?
Lifestyle
Do you smoke?
Are you a blood donor?
Please check any relevant box
Do you drink alcohol?
Are you generally feeling fit and well?
Food supplements taken?
Herbal remedies taken?
Do you exercise?
Rate your ability to relax
Poor
Excellent
Rate your diet
Very Unhealthy
Very Healthy
How many hours sleep do you get on average? Do you have difficulty getting to sleep, insomnia or any other disturbance of sleep?
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Consent
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I understand and have answered the above questions correctly and have not withheld any information. I also understand that my therapist advises on tools for well-bring and not diagnosis, which I should seek from my GP. I am happy to subscribe to the Holistic Cocoon newsletter.
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Any further comments?
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