Client Questionnaire
Thank you for contacting me about receiving Shiatsu.

For me to give you the most appropriate treatment, it is helpful for me to understand a little more about your lifestyle patterns and overall health.  I would be grateful if you could complete this questionnaire so I can support you through Shiatsu.  All data is stored carefully in accordance with GDPR rules.

Vicky Evans
Wye Valley Shiatsu
07749281625
Sign in to Google to save your progress. Learn more
Email *
Name *
Please confirm I have your consent to store your data for the purpose of a) maintaining my professional records and b) giving consent for treatment.  You can request data to be erased at any time by emailing me at wyevalleyshiatsu@gmail.com. *
Captionless Image
Date of birth
MM
/
DD
/
YYYY
Occupation
If you are under 18, I need to know the name and phone number of your GP and that you have parental permission to receive Shiatsu
Phone number
Why have you come for Shiatsu?
How would you describe your general wellbeing?
What is your sleep like normally?
How would you describe your usual diet?
How much tea/coffee/fizzy drinks do you have?
Do you smoke/drink/use drugs?  How often?
What is your energy like?
What do you find supports you in your life?
What is your relationship with family/loved ones like?
Have you had surgery, hospitalisations, or medical treatments for anything?  What?  When?  How did the treatment go?
Do you take any medication or remedies?  What effects do these have?
How do you like to relax?
How do you care for your spirit?
What brings you joy?
When you fall ill, what generally tends to happen?  
In a typical day when is your energy at its best and when is your energy at its lowest?
How is your menstruation cycle?  Have you been pregnant?
How well do you feel your bowels and urinary systems work?
How is your temperature generally?  
What would you say is your favourite colour?   Your favourite season?   Your favourite food?
And finally, what would you say is your superpower when all is well?
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