Are you under medical treatment now? If yes, please give details
List of current medications, herbs and supplements
List allergies: herbs, plants and others
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 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: _________________________________