|Home Phone||Postal Code|
|Referred by||Reason for Appointment|
|Are you under medical treatment now?|
|List current medications, herbs & supplements||List allergies: Drugs, Plants or other|
Please check any of the symptoms or physical problems listed below that you experience:
Are you currently pregnant or trying? Have you been tested for HIV? Positive ?
Do you have any skin conditions? Have you had a recent injury?
Are you in severe pain at this time? Have you taken pain medication today?
|Current Stress Level:||Low||Moderate||High|
DISCLAIMER: As a professional therapist, I do not make any claim of replacing any holistic or medical therapy. This therapy is of a complimentary nature only, rather than a curative treatment in itself. I adhere to the standards of practice and code of ethics set out by our respective governing bodies. I accept the responsibility of knowing what treatment that I want and have agreed to with this therapist.
Client's Signature of Consent for Treatment: ________________________________________________