스크랩 ITEC자격증_Consultation Form(영문)

[미영D]

Consultation FORM

                                                                       From Holistic Massage student Miyoung

First name:                                                            Surname:

Address:

City:

Post code:

Tel:

Occupation:

Dr’s name:

Address:

Medical History

(For Client’s Safety)

Have you ever suffered from any of the following?

                                                                                                          [Give details]

Asthma                                                                  yes/no

Respiratory Problems                                        yes/no

Diabetes                                                               yes/no

Endocrine problems                                           yes/no

Heart Condition                                                   yes/no

Epilepsy                                                                yes/no

Cancer                                                                  yes/no

Acute joint conditions                            yes/no

Varicose Veins                                                    yes/no

High/Low blood pressure                                   yes/no

Skin disorders                                         yes/no

ME                                                                          yes/no

Migration, Headaches                                        yes/no

Problems with veins/arteries                yes/no

Nervous disorder                                                 yes/no

Infectious diseases                                             yes/no

Allergies                                                                yes/no

Heartburn                                                            yes/no

Any other information:

Medication:

Homeopathy:

Date of last period:

Recent operation:

Emotional state:

Do you feel worried?                                                        Rarely/sometimes/often

Do you get neck, shoulder or back pain?                                  Rarely/sometimes/often

How are you energy levels?                                           Low/moderate/high

Do you have trouble falling asleep or staying asleep?  Rarely/sometimes/often

Stress levels:    1      2           3           4           5           6           7           8           9           10

Diet:

Daily diet contains how many of the followings?

Fresh fruit:                       proteins:                        fibre:

Fresh vegetables:             salt:                    sugar:

Daily beverage intake: Tea:            Toffee:       Other caffeinated drinks:

                                                   Soft drink:                     Water:

Alcohol consumption: no/ light/medium/heavy

 Units per week?

Exercise?    None/ occasional/ irregular/ regular

Type of exercise:

Skin type:

 Oily                       Normal                   Dry                          Combination

Reason for visit:

Declaration:

I declare the information I have given is correct as far as I am aware. I am willing to proceed with the treatment. I understand that this treatment does not substitute medical treatment. Information given by me is treated in strictest confidence.

(Client)

Signature:                                             date:

(Therapist: Miyoung Kim)

Signature:                                             date:

[미영D]

오래전 제가 공부할때 작성했던 consultation form 입니다.