Consultation Sheet
Name: Male/Female DOB: Date of treatment:
Address: Telephone: Occupation: Part-time / Full time:
Email:
GP name: Address: Telephone:
| Contra-indications: (tick any conditions applicable to client) Prevent treatmentdeep vein thrombosis □ severe skin disorders □ contagious skin diseases □ chemotherapy□ radiotherapy□ Restrict treatmentrecent operations □ high/low blood pressure □ dysfunctions of the muscular system □ | dysfunctions of the nervous system □ broken bones □ recent scar tissue □ hyper-keratosis □ allergies □ heart disease/conditions □ varicose veins □ cuts and abrasions □ epilepsy □ diabetes □ recent fractures □ pregnancy □ phlebitis □undiagnosed lumps and swellings □ respiratory conditions □ circulatory conditions □ medication □ General health: Good □ Average □ Poor □ |
| Lifestyle Energy levels High □ Low □ Average □ Stress levels High □ Low □ Average □Ability to relax High □ Low □ Average □Sleep pattern Poor □ Good □ Broken □ Dietary intake | Fluid intake Alcohol units per week Smoker □ Non smoker □ Exercise: daily □ weekly □ occasionally □ never □ Hobbies: |
| Any known health issues within the last 12 months? Yes/ No If yes please specify below | |
| State Treatment(s) having today: | |
| Modifications to treatment(s): | |
| Feedback from client: | |
| Home care advice given: |
Client signature:
Date:
Therapist Name & signature:
Date:
