Initial Client Consultation Form

General Information

Your Name (required)

Address (required)

Your Email (required)

Would you like to be added to our emailing list?

Date of Birth (required)

Occupation (required)

Contact Number (required)

Next of Kin (required)

Next of Kin Contact Number (required)

Do you have, or have you ever had any of the following conditions?
FeverInfectious or Contagious DiseasesRecent Surgery or Scar TissueBruising, Cuts or SwellingsArthritisOsteoporosisDiabetesEpilepsyAsthmaCardiovascular ConditionsTrapped NervesMultiple SclerosisHIV or AidsHigh or Low Blood PressureThrombosis or EmbolismCancer

If you said yes to any of the above can you please give details

Are you pregnant?
YesNo

If yes, how many months?

COVID-19 Specific Consultation

Do you currently have any symptoms associated with COVID-19? Or have you tested positive for COVID-19 in the last 5 days? If so, please get in touch before arriving for your treatment.

If so, can you please give details

Are you clinically extremely vulnerable to COVID-19? (Do you have or have had; an organ transplant, cancer treatment, radiotherapy for lung cancer, bone marrow or stem cell treatment, taking immunosuppressant medication, a severe lung condition, severe asthma, a serious heart condition or are pregnant?)

If so, can you please give details

Medical History and Family History

Current Medication

Doctor's Name and Address

Allergies (including nut allergies)

Family History of Illnesses

Diet and Lifestyle

General Diet

Vegeterian / Vegan
VegetarianVegan

Water Intake Daily

Coffee / Tea Daily

Other Fluids

Alcohol Units per Week

Smoke

Exercise

Sleep Patterns

Energy Levels

Stress Levels

Ability to Relax

Time for Yourself

Client Requirements and Expectations

What brings you here today? Do you have a specific ailment you would like to work on? Symptoms? Length of symptoms? What would you like to be different?

Treatment Choice

75 Minute Holistic Massage (Full Body) £4590 Minute Holistic Massage (Full Body) £50Holistic Massage (Back) £35Aromatherapy Massage £52Head Massage with Facial Acupressure £40Reflexology £40Reflexology for Pregnancy £40Holistic Facial £40Facial & Foot Reflexology £48Ear Candling £40Special Offer / Custom Treatment

By signing this box, I agree that the information given is correct to the best of my knowledge and I consent to receiving a treatment at Karuna Holistic Therapies.