Client Consultation Form Name * First Name Last Name Email * 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? Reason for treatment? If in Pain where is it? Are there times when the pain feels better/worse? What makes the pain feel better / what makes it feel worse? How long have you had the pain for? What would you like to gain from the session? If more than one issue what is the most important ? 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!