Client Name Date Fax
Street Address City Postal Code
E-mail Home Phone
Occupation Date of Birth
Referred By Family Doctor
Reason for Treatment
Are you under medical treatment now? If yes, please give details
List of current medications, herbs and supplements List allergies: herbs, plants and others
Allergies Diabetes Epilepsy Arthritis Scoliosis
Headaches Asthma Dizziness Weakness Indigestion
Sciatic High/Low BP Hearing Insomnia Vision
Cardiovascular Vascular Memory Fatigue Numbness

Back Pain Reproductive Sleep Sinus Migraines
Alcohol Chronic Fatigue Candida Ulcers Hepatitis
Cancer Thrombosis Bronchitis Warts Fungal Infections
Are you currently pregnant or trying? Have you been tested for HIV?
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 Health: Current Stress Level:

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: _________________________________