Jenny Sheridan - Essentials Holistic



Treatment: Aromatherapy Client’s Name___________________________________________________________________________E-mail_______________________________________ Phone ____________________________________Date of Birth_______________________ Where did you hear about me? ___________________________Would you like to be kept informed of therapy special offers? ___________________________Please circle your preference Yes NoAre you happy for me to securely store and keep your consultation form for legal reasons? Yes NoYour consent to holding your information is necessary for a treatment to be given. Main Reason for Treatment _________________________________________________________Are you happy for me to work on all areas including your gluts, feet, head, face, tummy? Medication (incl birth pill/HRT/Vitamins) ____________________________________________________Accidents, Illnesses, Injuries, Operations within the last five years _________________________________Do you suffer from any of the following conditions:- high/low blood pressure, epilepsy, sinusitis, diabetes, phlebitis/thrombosis, varicose veins, arthritis/rheumatism, gout, nervous system disorders, haemophilia, back complaint, migraine, headaches, anxiety/depression, insomnia, recurrent infections, skin conditions such as sensitive skin, eczema, psoriases, or any other condition? ______________________________________________________________________________________________________________________________________________________________________________Are you currently under the care of a doctor or other professional? _________________________________Do you have any allergies?_________________________________________________________________Would you describe your current levels of stress as low, medium or high? ___________________________Do you intend to use a sunbed/be in bright sunlight within the next 48 hours? ________________________Have you ever had a Massage/Aromatherapy/Healing/Reflexology treatment before? __________________What level of pressure do you like-light, medium or firm? ________________________________________Do you have a healthy diet?________________________________________________________________Do you drink water?______________________________________________________________________Do you take regular exercise?_______________________________________________________________Do you sleep well?_______________________________________________________________________General state of health:____________________________________________________________________For Female ClientsDo you suffer from PMT?__________________________________________________________________Have you given birth in the last 18 months? ___________________________________________________Is there any possibility you could be pregnant? _________________________________________________I have read the above and confirm the answers, whether completed by me or not are accurate.____________________________________ ___________________________________________ClientTherapistDateAfter care givenAdvice Given To ClientOther Advice Given i.e specific aromatherapy, advice Avoidance of strenuous activitiesYesNoFuture TreatmentsYesNoLifestyle/eating/exerciseYesNoStudent's Comments on Treatment e.g. What techniques did you use, how did it affect the client?Reflective Practice. How did you feel about your own performance i.e techniques, posture, client care etc? Any areas you need to improve on? ................
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