Consultation Form

Please complete and submit the Client Consultation Form below.

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.

Personal Details
Your Name*:

Your Email*:

Contact Number*:

Address:

Occupation*:

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:
LowModerateVigorous

Current stress levels:
LowMediumHigh

Current energy levels:
LowMediumHigh

Are you a smoker:
YesNo If Yes No./day:

General alcohol consumption:
LowModerateHigh

Are you on a special diet:
YesNo
If yes provide details:

Do you have any food allergies:
YesNo
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?):

Client Declaration
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):