Client Consultation Form
Name *
DOB *
MM
/
DD
/
YYYY
Mobile Number *
Email *
Home Address *
Where did you hear about me? ( Website, Instagram, Facebook or a friend) *
What is your occupation? *
GP details *
Next of kin details *
Skin Type *
If you ticked "other" please give details here
Hair Type *
Do you suffer from any of the following conditions? *
Required
If you ticked "other" please give details here
Are you suffering from any of the following contraindications? *
Required
Any additional information in relation to the above you feel your therapist should know? Please give more detail here *
Medical clearance and precautions
Clear selection
Any allergies? (Food, medications etc ) *
Do you exercise? If so what & when *
Are you taking any medication or Supplements? *
Hobbies & Pastimes *
Diet (normal, gluten-free, vegan) any issues? *
Daily fluid intake (water, tea, coffee, soft drinks) *
Smoking, alcohol and drugs
Heavy
Social/ medium
Occasionally
Never
Do you smoke?
Do you drink alcohol?
Do you take drugs?
Current stress levels *
Reason for appointment *
Please give details of any areas of tightness, pain or injury
Declaration - I hereby declare that I have answered the consultation form fully and I have not withheld any information that may affect the outcome of the treatment. I know of no reason why I cannot undertake the treatment. It is my responsibility to notify the therapist of any medical changes that may affect any treatment either now or in the future. *
Required
I give permission for you to hold my records to deliver your services *
Required
COVID 19 Declaration form - To help prevent the spread of COVID 19 in the clinic and community, we ask each patient to complete and submit this form before attending for treatment. On review of your form, the practitioner may contact you to ask you not to attend at this time and will discuss suitable future appointments for your treatment. We have taken extra measures to safeguard our patients prior to arrival. We kindly ask you to complete this declaration for the safety of you, our patients and therapist. **Guardian of a child or vulnerable adult having a treatment, please complete on their behalf
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu-like symptoms now or in the past 14 days? *
Have you been diagnosed with confirmed or suspected COVID 19 infection in the last 14 days? *
Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (less than 2 metres for more than 15 mins accumulative in 1 day) *
Have you been advised by a doctor to self-isolate or cocoon at this time? *
Do you consider yourself to be in the category of people at high risk from COVID19? if you are unsure please visit - https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html *
Have you travelled outside of Ireland in the last 14 days? *
If your situation changes after you complete and submit this form, you agree to inform your therapist *
Required
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