Consultation Form - Health declaration

Please fill out the following form.

First name

Last name

Email

Date of birth

Day

Month

Year

Address

Doctor's name, Telephone and Address

Next of kin's name and phone number

Reason for seeking treatment:

YOUR HEALTH

Are you receiving any treatment or taking any medication for any specific problem?

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Have you previously had any significant accident, illnesses or operation?

Do you currently have any of the following conditions?

If yes to any of the above, give details:

Have you had any broken facial bone, broken nose, facial trauma?

Have you had any facial cosmetic work? (Surgery, Botox etc.)

Have you had any dental work done in the recent three month? Do you have any dental issue?

Do you grind/clench your teeth? Please give details

Do you suffer with allergies of any kind?

Do you suffer with any type of skin disorder? Is your skin hypersensitive?

Would you say that you have good levels of energy? (Are you often tired?)

Do you have trouble getting to sleep, or waking during the night?

Do you take some form of regular exercise?

Do you ever have difficulty breathing? Or feel congested with mucus? Or sinusitis?

Do you often get headaches? If yes pl give details

Do you eat regular meals?

yes

no

sometimes

Do you ever feel bloated and uncomfortable after eating? (Are you prone to indigestion?)

yes

no

sometimes

Are you ever constipated?

yes

no

often

Do you regularly consume the following?:

Sugary foods and drinks (fizzy)

Cheese or butter

Deep fried foods

Caffeinated tea and coffee

Water (how many liter/glasses)

Are you a smoker?

yes

no

occasionally

What is your weekly alcohol consumption?

FEMALES:

Is there any possibility you may be pregnant?

Do you menstruate regularly?

Do you suffer with PMT, menstrual pain or menopausal symptoms? Or any gynecological issue?

STRESS AND EMOTIONAL WELLBEING

How stressed are you, and how well do you cope with stress?

How would you describe your emotional well-being?

Are you aware of negative emotions affecting your health and creating symptoms in your body?

Do you practice relaxation techniques/meditation?

CLIENT CONSENT

Please read carefully.

I have completed this form to the best of my knowledge and have disclosed information about any condition that I am currently aware of.

I understand that Veronica Massa is not a medical practitioner and does not diagnose illness, disease or any other physical or mental disorder. I understand that Veronica Massa is not a substitute for medical examination, diagnosis, or treatment.

Cancellation Notice & Fees

I agree to give as much notice as possible if I need to cancel or re-schedule an appointment with Veronica Massa and accept that I will pay the below rates for late cancellation:

Less than 24hrs 100% of the fee

If you wish to proceed with the treatment:

I confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed. I hereby indemnify the therapist against any adverse reaction sustained as a result of the treatment.

Signature

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Date

Day

Month

Year