For Female Clients - Essentials Holistic

 Consultation Form Client’s Name___________________________________________________________________________E-mail_______________________________________ Phone ____________________________________Date of Birth_______________________ Where did you hear about me?___________________Would you like me to keep in touch regarding special offers, new therapies and wellness tips?Please circle your preference Yes NoAre you happy for me to securely store your consultation form? Yes No(For insurance purposes, I can’t treat you unless I can store your consultation form).Main Reason for Treatment ____________________________________________________(Massage/aromatherapy only) Are you happy for me to work on:- 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.____________________________________ ___________________________________ClientTherapistDateIf any of the following apply to you, you could become severely ill if you contract covid 19. For your own safety, I won’t treat you at the moment. Are you 65 or over?Do you live in a nursing home or a long time care facility?Have you recently had a bone marrow or organ transplant? Have you been using corticosteroids for a prolonged time?Do you smoke?Do you suffer from chronic lung disease, moderate to severe asthma, a heart condition, cancer, immune deficiencies, HIV or Aids, severe obesity, diabetes or liver disease?Have you or anyone you have been in contact with tested positive for covid19, waiting for test results or waiting to have a test? For everyone’s safety at this time, I am screening all my clients.The following are common symptoms of covid 19, I can’t treat you if you have any of them:-Fever, Dry cough, Fatigue, Chills, Body aches, Headaches, Loss of taste or smell, Sore throat, Confusion, Mild diarrhoea & nausea, Conjunctivitis, Congestion, Skin rashes, Blisters, Inflammation, Shortness of breath.I have introduced policies to keep everyone safe Option 1To minimise the risk of touching an infected surface:-Everything touched by any client before you will be sanitised.I will advise you to drink water when you leave but I can’t supply it. Towels, plinth covers etc will be removed after each client and stored in a sealed bag. away from the therapy room.Windows and doors will be left open as much as possible during and after treatments.All surfaces will be sanitised after each client.Clients are asked to bring nothing but their keys into the building with them.Clients are asked not to touch anything unnecessarily, everything that is touched will be sanitised. To minimise any droplets in the air:-Every client will be asked to bring and wear a mask. I will have antiviral essential oils burning at all times. Talking will be kept to a minimum.To avoid unnecessary contactThe waiting area/reception will be empty at all times.Clients will be asked to wait in their car until they get a text to come in.Clients will be asked to take their temperature when they arrive. If it’s high the appointment will be rescheduledThere will be no cancellation fee during covid 19Are you happy to work with me in maintaining these policies as long as they are necessary?I have introduced policies to keep everyone safe Option 2Here’s what I’ll ask you to doIf you have any of the symptoms above, please reschedule your appointment.Wait in your car until I text youBring a mask and wear it in the buildingDon’t bring anything unnecessary into the building - keys only if you’re driving, keys and phone if you’re walkingWash your hands with essential oil-infused soap supplied when you arrive and before you leave Take your temperature when you arrive, the appointment will be rescheduled if your temperature is highKeep talking to an absolute minimumDon’t touch anything unnecessarily, everything that is touched will be sanitised. Place your keys (and phone) on the paper providedSanitise your hands with sanitiser provided whenever necessaryCough into your elbowAre you happy to work with me to keep yourself, me and others safe? AgreementFor distant consultations, I will send you a copy of the completed consultation form.Please email back that you agree that the answers in the consultation form are correct.Thank you! ................
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