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Holistic Therapies Questionnaire and Disclaimer

       

All information is strictly confidential

Name:

           

E-mail:

           

Home Tel:

         

Mobile:

Address:

           

Post Code:

           

Age Group

Under 16

Over 16

   

Do any of these health conditions apply to you?

 

If yes, please give details

Arthritis

     

yes

no

 

Back Problems

     

yes

no

 

Breathing Problems

   

yes

no

 

Depression

     

yes

no

 

Diabetes

     

yes

no

 

Eye Problems

     

yes

no

 

Heart problems

     

yes

no

 

High/Low blood pressure

 

yes

no

 

Knee Problems

     

yes

no

 

Neck Problems

     

yes

no

 

Pregnancy

     

yes

no

 

Recent Fractures/sprains

 

yes

no

 

Recent Operations

   

yes

no

 

Other

     

yes

no

 

I will inform my therapist of any changes to my medical status.

Disclaimer

I have, following consultation, consideration and discussion, agreed to undergo this therapy. I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment.

I understand the information I have been given to be the truth and consent to the treatment of

been given to be the truth and consent to the treatment of I have had the

I have had the procedure explained to me and understand the nature of the treatment. I fully understand this

treatment is not a substitute for medical treatment and it may take several sessions before I notice any benefit. This

will depend on my life style, on-going medication and general health.

I acknowledge I have given my personal details for the holistic providers use. I understand that my information is protected and I give my consent for the company to store and use my details. I understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected.

The therapist does not claim to cure or to diagnose any medical condition in the same regard as a physician, as their opinion is that of a holistic, complementary and alternative therapist and their professional opinions, advice, examinations and recommendations do NOT constitute the medical advice of a doctor/physician.

I will seek the advice of my doctor or other qualified health provider in the case of a medical emergency, medical ailment or in respect of general health questions without delay.

Client Signature:

Date: