Your name
Your email
Presenting Conditions and medical diagnosis (if any)
How does this affect your day to day activities/hobbies
What aggravates your symptoms and what gives you relief
How does this condition affect you generally (sleeping pattern/anxiety/stress levels etc…
Clients expectation of treatment:-
Acupuncture; Auricular Acupuncture; Bowen Therapy; Bowen Lymph work; MSTR Scar work; B12 injection. A
Medical Checklist
Current Medication
List and date previous operations
Epilepsy---YesNo
Heart Disease/BP---YesNo
Currently Pregnant---YesNo
Fractures ---YesNo
Digestive ---YesNo
Respiratory ---YesNo
Genito/Urinary ---YesNo
Circulatory ---YesNo
Allergies ---YesNo
Whiplash Injury ---YesNo
Other Health Issues