Client Intake Form Name * First Name Last Name Date of Birth MM DD YYYY Occupation Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Relationship Status * Number of Children If Applicable Why are you seeking treatment? * Any other relevant information? Are you receiving other therapies regularly? If so, what are they? GP's Name First Name Last Name GP Surgery The name and address Diagnosed Medical Conditions & Medication Details * Medical Health History Describe your diet * What do you drink in a day? * Bowel & Urinary Health Smoking / Alcohol What do you do for exercise? What do you do to relax? Describe your sleep patterns How would you rate your energy levels? How would you rate your stress levels? Consent * I declare the information in this form to be true and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive reflexology and any other therapies as listed above. (Privacy Policy found underneath form) I agree to the Privacy Policy. Check this box if you're signing up on behalf of a child. (Under 16) Today's Date * MM DD YYYY I’m honoured to be a part of your potential.I’ll get back to you as soon as possible, thank you for taking the time to write this form. Privacy Policy Book your Chemistry Call
