top of page

Health Questionnaire


Email Address*


Post Code*

Date of Birth

Contact Phone Number*

Emergency Contact*

Emergency Contact Number*

GP Surgery Name *

Current Medication list

Have you had Covid Vaccine/s*

When was your last Covid booster ?

Are you under Hospital Care at the moment?*

Consultant Name:

Hospital Address

Have you ever tested positive for Covid ?

If YES, what date ?

Tick if apply to you*

Any boxes you ticked please briefly explain

Medical consent for treatment*

Treatment consent

Thanks for submitting!

This is a confidential health questionnaire that must be filled out by every client before treatment or therapy commences. Please answer the questions as fully as possible. 

It is important that you answer all questions the best you can to enable me to advise and assess your suitability for each therapy.

If you are unsure of any answers you can discuss with me by phone / text or email.

This information is for my use only and will not be given to a 3rd party . Your information will be stored under GDPR regulations

Just put your curser where you want to type and your keyboard should come up.

when finished press submit. 

bottom of page