Consultation Form - Naturra

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Consultation Form

Home
Shop
Offers
My account
About
Blogs
Contact
Resources

Home
Shop
Offers
My account
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Blogs
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Contact Hours: Monday-Friday 9 am - 5pm. Free shipping over £50

Consultation Form

Please share the information below to assist me in understanding you and your concerns.
Complete the form as thoroughly as possible. All information will be held confidentially and in accordance with GDPR regulation.

Personal Information

First Name

Last Name

Gender

DOB

DOB

DOB

Address

Post code

Mobile

Email

Marital Status

Dependants

Emergency Contact Name

Tel No

Height

Weight

DOCTORS DETAILS

Doctor Name, Address & Tel No

Date of last visit to the GP & reason:

Medication – Prescribed and over the Counter/Supplements:

Operations/Accidents/Illnesses incl. dates:

PERSONAL AND CLOSE FAMILY MEDICAL HISTORY (Blood Relatives Only)

Do any of your close relatives suffer from the following medical issues?

Vascular

None Heart Hypertension Poor circulation Thrombosis Varicose Vein

Endocrine/Immune

None Diabetes Thyroid ME Lupus (SLE) Headaches

Nervous Disorders

None Epilepsy Depression Migraines MS Headaches

Digestion

None Indigestion Constipation Ulcers Colitis Diarrhoea/IBS

Respiratory

None Chest Asthma Bronchitis Hay Fever Sinusitis

Skin

None Eczema Allergies Psoriasis Athlete’s Foot Verrucae

Genito Urinary

None Kidney Bladder Infertility Other

Other

None Cancer Arthritis Rheumatism Hepatitis

Disabilities

None Mental Health Physical Congenital Other

Special Senses

None Eye defects Contacts Anosmia Deafness Other

Are you suffering from any infection diseases?

YES NO

Childhood illnesses:

Details on Medical History (to include details of X-rays and other medical tests/diagnosis):

Total Contraindications:

Infectious/notifiable disease Current Migraine Undiagnosed Oedema (consult GP) Unexplained pain or inflammation (consult GP)

Local Contrandications/Cautions

Pregnancy Scar tissue/cuts/open wounds or sores/lacerations Varicose Veins Allergies Epilepsy Asthma Medications Hepatitis Parchment Skin

Skin Type:

FEMALE HEALTH

Describe any issues with women’s health and/or Menstrual Cycle:

Date of first day of last menstrual cycle:

Pregnancy: If you are pregnant how many weeks?

NOTES ON CONTRAINDICATION/CAUTIONS/SKIN ISSUES WHERE APPLICABLE

GP LETTER

Date sent: (if applicable)

Date of Reply:

Are you currently receiving treatment by a health care professional, either complementary or orthodox, including dentist or optician? Details

Have you received this essential oil therapy before?

How did you hear about me?

LIFESTYLE

How are you feeling Physically today/lately? (on a scale of 1-10)

How are you feeling Emotionally today/lately? (on a scale of 1-10)

What do you hope to gain from this treatment?

What is your diet like?

How much fluids do you drink per day?

Do you smoke?

Yes No

If you smoke then number per day

Do you drink?

No Yes

If you drink then number of units per week:

Describe your sleeping pattern

Is your life stressful and if so why?

On a Scale of 1 – 10 How would you rate stress levels?

How do you cope with stress?

Do you take any regular exercise?

How would you describe yourself?

Optimistic Pessimistic Confident Nervous

Have you suffered any bereavements, if so when?

Do you have any phobias?

CLIENT DECLARATION

I understand that submitting this form I confirm that all the information given during this consultation is accurate to my knowledge and I consent to receiving aromatherapy treatment

Client Name/Guardian (Print)

Signature:

Date:

Therapist’s signature:

Date

Customer Service

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34 New House 67-68 Hatton Garden London EC1N 8JY
contact@naturra.co.uk
07415 253 535
07415 253 535

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