Medical History

Please fill out your details before your therapy session. This information is strictly confidential and will only be used to ensure that your treatment is safe, appropriate and effective. If you prefer you can fill out a paper copy in the therapy room before your appointment.

First Name *

Last Name *

Email *

Phone

Please tick if you have any of the following medical conditions -

HERNIATED BULGING DISCS
OSTEOPOROSIS
WHIPLASH
ARTHRITIS
FIBROMYALGIA
NUMBNESS 0R MUSCLE WEAKNESS
RECENT OPERATIONS (3 to 6 Months)
RECENT FRACTURES ( 3 to 6 months )
HERNIA
HIGH / LOW BLOOD PRESSURE
VARICOSE VEINS
ANY UNDIAGNOSED LUMPS OR BUMPS
ANY CUTS, BRUISES ABRASIONS, INFLAMATION
ALLERGIES
RECENTLY TAKEN PAIN KILLERS OR BLOOD THINNERS
CANCER
DIABETES
EPILEPSY
FUNGAL / SKIN CONDITIONS
HEART CONDITIONS
INFECTIOUS DISEASES

Do you have any other conditions or concerns ?

Are you currently experiencing discomfort, pain or limited movement ? Which area is it effecting?

What would you like your treatment to focus on ?

STRESS RELIEF
REDUCED ANXIETY
PAIN REDUCTION
INCREASED MOVEMENT / FLEXIBILITY
REDUCED MUSCLE TENSION
SELF CARE

Declaration

I have completed the form as fully and accurately as I can. I believe the details to be correct and consent to having treatment with the practitioner at Anam Cara. I release the practitioner from any negligent misrepresentation that may be contained in this form.

Thank you for completing your medical history online

This information is strictly confidential and will only be used to ensure that your treatment is safe, appropriate and effective. It will be stored securely.

I look forward to helping you relax and enjoy your therapy session.

Julia Williamson

Thank you for completing your medical history online

This information is strictly confidential and will only be used to ensure that your treatment is safe, appropriate and effective. It will be stored securely.

I look forward to helping you relax and enjoy your therapy session.

Julia Williamson

Medical Questionnaire

Subscribe to our emails