05
Mar

Consultation Questions To Consider For Holistic Therapies

Always check in with me before your appointment to ensure you are suitable for the therapy that you have booked in for. I do require your Healthcare Providers consent if you are attending a consultant for some medical condition, and always ask for a telephone consultation before your appointment. This avoids disappointment. If it’s Oncology massage then this is definitely required. I do also check your suitability for any workshops that I may run out in the community. Below is a quick example of a consultation form that I will need filled in before we proceed with your therapy.

KAREN GIBSON CONSULTATION FORM – Example

Please note this form must be kept for a minimum of 7 years for insurance purposes (all sections with a * need to be completed)

*Client name _____________________________________

*Date of birth ______/________/________

*Address __________________________________________________________

*Postcode ___________________                 *Contact number _______________________________________

*Email address ____________________________________________________

What communications would you like to receive from me?

Appointment Reminders □   Promotions, news, last minute apps group

*Doctor’s name and address ___________________________________________________________

*Any other medical conditions/ailments/medication       yes/no

(check list below)

Please specify if you are currently attending any medical current medical care / medication

If any are marked yes, please let me know.

Prone to keloid scarring yes/no

Hormone imbalance yes/no

Stroke yes/no             Migraines  yes/no  when?

Claustrophobia yes/no

Hepatitis yes/no           Dental implants yes/no

Metal plates/pins/piercings yes/no- where?

Recent scar tissue/surgery yes/no – When?

Respiratory problems yes/no            inhaler? Y / N

Allergies yes/no – what?

High/low blood pressure yes/no – controlled?

Operations within 6 months yes/no

 

Heart conditions/pacemaker yes /no                   Operations within 6 months yes/no

Severe circulatory disorders/DVT yes /no         Diabetes yes/no         controlled?

Skin disorders yes/no                                            Kidney problems yes/no

Swelling/oedema yes/no                                       Haemophilia yes/no

Cancer yes/no            when?

Limitation of body movement/arthritis yes/no

Are you pregnant yes/no              weeks_______

Epilepsy yes/no

Additional information to let me know if you are currently are using  – fill in if relevant parts.

Retinol or Roaccutane yes/no    Products containing fruit acid yes/no Microdermabrasion yes/no    Laser/IPL yes/no     Botox or fillers yes/no

 

Ultra violet exposure or heat treatments before 48hrs appointment yes/no

Any other relevant information?

*Declaration I declare that the above information I have given concerning my health is correct and I fully understand my after treatment care.

Signature       ________________________                                              Date______/______/_______

 *Updates/Changes. Please advise me of any personal or medical changes applicable to this consultation form since your last treatment with me? If none, state NONE with your signature and date.

Extra information for other treatments.

Any questions always ask.