Client Questionnaire

You are not obliged to provide any information requested on this form. All information you do provide will be treated in the strictest confidence and stored in accordance with the General Data Protection Regulations. Information is only held when it is necessary for me to carry out my work and when you have given me permission to do so. For further information about your data protection rights please visit: https://ico.org.uk/your-data-matters/

Full name *

Phone number

Email address

Emergency contact (name & number)

The following questions are asked to help ensure your safety; there are certain conditions that require my special attention. Please consult a health professional if you are unsure about attending our appointment.

Do you have any conditions that affect the following body systems? Please select all that apply.

Please provide further details

Do any of the following apply to you? Please select all that apply.

Please provide further details

Is there anything else that you wish to bring to my attention?

I confirm that the above information is accurate to the best of my knowledge and agree to take responsibility for my own health and safety

Date *

I agree to the terms and conditions laid out in the Privacy Policy *