Consultation form – Kenbiki Holistic Massage

Consultation forms

Kenbiki

Have you decided which treatment to go for?
Gain more time to relax and avoid possibility of forgetting something during filling the medical history form. Fill in the form online so you don’t need to print it. It will wait for you to sign when you arrive.

This consultation is obligatory to identify if there are any contra-indications that would affect you having a treatment. This is also to safeguard you as well as the therapist.

Body massage

Personal details

Address

DOB

Occupation

Date

Referred by

Phone number

Do you suffer of have you suffered with any of the following (tick if yes):

Any recent head or neck injury Severe bruising on an area treated Allergies Hayfever Sinusitis Eczema Psoriasis Diabetic Epileptic Recent haemorrhage High blood pressure Low blood pressure Migraines Headaches Thrombosis or embolism Heart problems Varicose Veins Multiple Sclerosis Arthritis Rheumatism Menstruation Birth Pill PMT Menopausal Anxiety Depression Kidney Problems Indigestion Gallstones Constipation Diarrhoea Asthma Eye Problems Ear Problems Insomnia Spastic conditions Dysfunction of the nervous system Scalp infections Cuts or abrasions in area being treated after recent operation Are you pregnant Are you currently taking any medications

Name and address of doctor

Do you drink alcohol? If so how often?

1 2 3 4 5 I don't drink

Do you smoke? If so how many a day?

1 2 3 4 5 More I don't smoke

Energy level

1 2 3 4 5

How would you say your stress level

1 2 3 4 5

Details if levels are high

What are your hobbies? How do you relax?

Why have you come for a Body Massage?

Areas of tension

Comments

Disclaimer

Indian Head Massage

Personal details

Address

Surgery details

DOB

Occupation

Date

Referred by

Phone number

Have you had or are you suffering from Cancer?

Yes No

Do you have allergies to? (tick if yes)

Nuts/Oils Hayfever Sinusitis Eczema Psoriasis Any other known

Are you/could you be pregnant?

Yes No

Do you suffer from/or have any of the following? (tick if yes)

Heart Problems High Blood Pressure Varicose Veins Multiple Sclerosis Arthritis Rheumatism Broken Bones/Strains Recent Scar Tissue Menstruation Birth Pill PMT Menopausal Anxiety Kidney Indigestion Gallstones Constipation Diarrhoea Asthma Eye Problems Ear Problems Migraine Headaches Insomnia Nervous Stress Depression Spinal - Posture Shoulders Back Neck Lumbar

Recent operations?

Do you have any other medical condition/illness?

Are you on any medication?

Name and address of doctor

Doctor's phone number

Are you intending to sunbathe or use a sunbed within the next 24 hours?

Yes No

Do you take supplements?

Yes No

Do you drink alcohol? If so how often?

1 2 3 4 5 I don't drink

Do you smoke? If so how many a day?

1 2 3 4 5 More I don't smoke

Approx how much fluid do you take each day?

Do you exercise?

Yes No

Type (if yes)

Is there any other heath condition, which you think would affect you having therapy?

Disclaimer

I have answered the questions truthfully. I understand the therapist has gone through this consultation with me, to identify if there are any contra-indications that would affect me having a treatment. I also understand that this is to safeguard me as well as the therapist. I therefore do not hold the therapist KAMILA GLASEK liable.
(Some Clients may have the following symptoms for up to 48 hours after a therapy. Headaches, Emotionally Upset, Lethargic, Energized, Flu Like, Achy. This is a result of your mind and body absorbing the essential oils.)

Ear Candling

Name

Address

DOB

Occupation

Date

Referred by

Phone number

Client No.

Presenting Condition (Tick where applicable)

Sinus/rhinitis Headaches Migraines Earaches Tinnitus Glue Ear Excess/compacted wax Catarrh Hay Fever Colds Sore Throats Snoring Pressure problems Menieres disease Other (notes below)

Contraindications/Precautions (Tick where applicable)

Perforated eardrums Ear grommets or tubes Cochlea implant Infectious diseases/disorders Eczema/dermatitis/infections in outer ear Acute/infectious disease High temperature/fever/ heavy cold Recent Head or neck injuries Under influence of alcohol or drugs High/low blood pressure Toothache/dental work Oil in ear Allergies to ear candle treatment Recent Operations/scar tissue Cysts/lumps Serious medical conditions Other (specify below)

Other

Disclaimer

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