Complementary Therapy Clinical Assessment

Complementary Therapy Medical Assessment form

Step 1 of 3

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Name(Required)

Prefix First Last

Address(Required)

Address line 1 Address Line 2 City County Post Code

Phone(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Occupation

General State of Health

Do you exercise regularly?(Required)

Yes

Are you taking any medication?(Required)

Yes

How would you describe your stress levels?(Required)

Low

Medium

High

How would you describe your energy levels?(Required)

Low

Medium

High

Are you on any special diet?(Required)

Yes

Do you smoke?(Required)

Yes

How many cigarettes per day or vape

Do you drink alcohol?(Required)

Yes

How many units per week

*Approximate values 1 pint- 2 Units. 1 standard glass of wine 2.1 units. Single shot of spirits- 1 unit

How would you describe your sleep pattern?

What do you do for relaxation?

Have you ever had any complementary therapy?

Yes

Reason for Treatment

(Female Clients)

Are you or could you be pregnant?

Yes

Unsure

Please state how many months

Are you currently breast feeding?

Yes

Have you had an iud fitted in the last 12 weeks?

Yes

Date of last period

DD slash MM slash YYYY

Medication

Please list any medication you are currently taking including supplements recreational drugs ?(Required)

If not applicable, please type N/A

Do you have any side effects from any of the medication listed?

Have you had any recent changes to your medication – i.e increased/lowered dosage?

Conditions and symptoms

Do you suffer from or have in the past (please check all that apply)

Heart disorder including high or low B/P atrial fibrillation/pacemaker, angina

Respiratory problems including history of Bronchitis/COPD/Emphysema/Asthma

Lymphatic Oedema/lymphoedema/clients perceptions of circulation

Thrombosis/embolism

Epilepsy

Dysfunction of the nervous system

Any infectious diseases

Skin disorders and/or sensitivities

Sever bruising

Scar tissue any recent scar tissue x12 weeks

Suffered from any swelling/oedema

In the last x12 weeks had any operations

Had any inoculations x weeks

Recently suffered from a haemorrhage

Varicose Veins

Cancer

Do you suffer from or have in the past (please check all that apply)

Had or are currently undergoing any radiotherapy / chemotherapy

Bone Metastasis

Any fractures or recent sprains

Digestive Disorder

Liver disorder

Kidney Disorder

Nausea/vomiting

Diabetes

Osteoporosis

Arthritis

Back problems

Allergies

Anxiety or depression

Headaches or Migraines

Reproductive -

Operations – including any pins or plates

Do you have any other medical condition?

If you have checked any of the boxes above, please give more information on each one

Please avoid alcohol and eating a heavy meal prior to treatment. If you are unwell and are suffering from a fever please inform the service to rearrange any sessions

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