BB Holistic Therapy Consultation Form

It is imperative that I have the most up to date information of your contact details, health and wellbeing to ensure your treatment is adapted to your needs enabling the best possible treatment. In the current ever-changing climate and guidelines, it is necessary to ensure both insurance and government legislation is upheld. You must complete this form and return it prior to your treatment, to ensure it is able to go ahead.

PLEASE DO NOT ATTEND YOUR TREATMENT if you have had any symptoms of COVID-19 or are currently unwell. Please arrange your appointment for an alternative time.

Name

Address

Occupation

Phone

Date of Birth

Doctors Name and Practice

Have there been any recent changes to your health and wellbeing?

Do you have any other health conditions not mentioned above? If so, please provide further details.

Are you currently taking any prescription medication? If so, please list name and dosage.

Do you have any allergies?

On a scale of 0-10, where 0 would mean you were not suffering from any stress and 10, extreme stress, where would you put yourself on that scale?

Are you currently suffering with any pain anywhere in your body? If so, where? What is the nature of the pain e.g. dull/sharp, constant/intermittent, bearable/unbearable. What impact does it have on your lifestyle e.g. minimal, moderate, severe.

How would you describe your general well-being?

Is there anything else you would like BB Holistic Therapy to be aware of in preparation for your upcoming treatment?

How do you currenlty look after your wellbeing and selfcare?

Are you currently Pregnant? If so how many weeks

Where did you hear about BB Holistic Therapy

Google search

Facebook

Instagram

Personal Recommendation

Other

GDPR & Data Storage

I agree for BB Holistic Therapy to hold my details on file and on a computer in accordance with GDPR Guidelines May 2018.

I would like to receive email updates and the latest news from BB Holistic Therapy

If client is under the age of 18 years, parental or guardian consent for treatment is required. Do you have parental responsibility?

Yes

Not applicable

Thanks for submitting!

20 Winchester Road, Alton, GU34 1RX, United Kingdom

bbholistictherapy@gmail.com | 07533 451985

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