Green Room Therapies is committed to keeping your data secure and only uses it for the purposes of providing the most appropriate treatment.
Please read the attached Privacy Notice.
Date of Birth* (dd/mm/yyyy):
Doctors Name & Practice*:
Female Clients Only
Could you be pregnant? If yes how many weeks:
General Health & Lifestyle
Current level of exercise:
Current stress levels:
Current energy levels:
Are you a smoker:
YesNo If Yes No./day:
General alcohol consumption:
Are you on a special diet:
If yes provide details:
Do you have any food allergies:
If yes provide details:
What fluids do you consume in an average day (e.g. 5 cups of tea):
How would you describe your sleep patterns:
What do you do for relaxation:
What are you looking to achieve from this treatment. E.g. relaxation or something more specific to a condition:
Conditions and/or Symptoms
Have you suffered (past or present) with any of the following conditions (tick all that are applicable):
Cardiovascular disease/stroke/cardiac arrestVaricose veins/phlebitis/thrombosiaDiabetesHigh/Low Blood PressureGeneral circulation or heart problemsGynaecological issuesEpilepsyHormone imbalancesBack or neck problemsWater retentionSwelling/OedemaSkin disordersCurrent conditions of the feet e.g. verrucaeCancerOsteoporosisArthritisHeadaches/MigraineAsthma or any respiratory conditionAllergies (hay fever)Depression/any mental health condition
If you have any other medical condition not specified on the list above, please note it down here. Additionally, for any condition you have had, please give further information if you feel it's applicable:
Please provide details of any medication or supplements you are currently taking (Name? Take for what purpose? How long have you been on this medication? Any side effects?):
I declare that the information that I have given is true and correct and, as far as I am aware, I can undertake treatment without any adverse effects. I have read about the contra-indications to treatment on the website and am willing to proceed. I understand this is not a substitute for medical advice and/or treatment.
DECLARATION I have read and understood Green Room Therapies Privacy Notice document and understand that you will hold and use my personal information, using it in order to provide me with the best possible treatment options.
I have read and understand the Privacy Notice
Client signature (please type full name) (Parents to consent for Under 16s):
Today's Date (dd/mm/yyyy):