Bodywork Consultation Form

I appreciate you taking the time to complete the following consultation form as best you can. Each question will be discussed at your consultation to ensure that nothing is missed, but the more information you provide here, the better I can tailor your consultation and subsequent treatment to your needs. 

Please complete and submit this form prior to your consultation.

Many thanks

Jade

Personal Details
Name *
Name
Address
Address
Date of Birth
Date of Birth
Emergency Contact Name
Emergency Contact Name
Name of Doctor
Name of Doctor
Doctor Address
Doctor Address
General Health and Lifestyle
How would you describe your stress levels?
How would you describe your energy level
Please list allergens and possible reactions
Female Clients
Date of your last period
Date of your last period
Conditions and/or symptoms
Do you have/have you ever suffered with any of the following conditions?
Please check all that apply
Your personal data will be stored and be accessible by Meant to Bee Therapies - Jade Adair Your information will not be shared to any third party companies. We will only contact you with regards to Meant to Bee Therapies and associated matters and will never send spam to you. Medical Malpractice: Your details will be kept on record for 3 years once you have recieved your last treatment with Jade Adair Record Keeping Your consultation forms are kept on file on a password protected computer and paper files are kept in a locked filing cabinet at my home address. Your files are not viewed or accessible by anyone other than Jade Adair, unless consent is given by yourself to share with other therapists. Medical Information Required The medical & emotional questions are required so that Jade Adair can provide a Holistic Treatment for you.