Name * First Name Last Name Email * Are you happy to be contacted by email * YES NO Phone Medical History Do you Have any medical conditions? Are you on any medication? if yes what is it for? Have you had any operations/broken bones? Is there any additional information you'd would like to tell me? Such as long term chronic pain, injury or stress. What would you like to gain from the session? What does you average week look like e.g work/children/exercise On a scale of 1 to 10 how are your stress levels on a weekly basis. Where 1 is being relaxed and 10 feeling totally overwhelmed Sign and date Thank you! Client Consultation Form