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Client Consultation Record

Please complete this form before your first session. All information is kept strictly confidential.

11. Personal
22. Lifestyle
33. Medical
44. Conditions
55. Consent

Personal Details

Emergency Contact

Lifestyle Details

Recent Healthcare Visits

Have you visited any of the following in the past 6 months? (tick all that apply)

Medications

Historical Medical Conditions / Operations

Current / Recent Conditions

Please indicate if you currently have, or have had in the past 6 months, any of the following. Select Yes to provide details.

Musculo-Skeletal Problems
e.g. Strains / Sprains / Fractures / Myositis / Joint Replacement / Arthritis / Osteoporosis / Bursitis / Tendonitis
Circulatory Problems
e.g. Heart Condition / Hypertension / Hypotension / DVT / Phlebitis / Varicose Veins / Haemophilia / Cardiovascular disease
Neurological Problems
e.g. Epilepsy / Sciatica / Neuralgia / Multiple Sclerosis / Parkinson's
Skin Problems
e.g. Eczema / Acne / Athlete's Foot / Warts / Dermatitis / Psoriasis / Impetigo / Cuts / Bruises / Burns / Undiagnosed Lumps
Respiratory Problems
e.g. Asthma / Pneumonia / Bronchitis / Sinusitis / Cold / Cough / Flu
Immune Problems
e.g. Cancer / Rheumatoid Arthritis / HIV / AIDS
Digestive Problems
e.g. IBS / Constipation / Diarrhoea / Gall Stones / Kidney Stones / Urinary Tract Infection
Miscellaneous / Other Problems
Any other conditions not listed above

Declaration & Consent