Booking – Crown 2 Heeling Ayurvedic, Holistic Whole Body

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1Consultation Form

2Booking Form

Name

DOB

Phone

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Checkboxes

Please check this box if you have NO medical conditions or circumstances. Otherwise circle any that apply in the below lists.

Medical Circumstances

TOTAL

Diarrhea / diarrhoea

Fever

Vomiting

Pregnancy

Head lice

Intoxication (alcohol or recreational drugs)

MEDICAL PERMISSION

Recent operation/surgery

Severe and unexplained headaches

Any medical condition affecting the neck

Swelling in a particular area (localized)

Undiagnosed pain, lumps or bumps

Currently taking a prescribed medication

Medical condition already being treated

Medical conditions not listed on this form

LOCAL

Acne

I've just had a heavy meal

Bedsores

Blisters

Injuries (acute or undiagnosed)

Currently menstruating

Recent abrasions, bruises, cuts, swelling, areas of inflammation

Sprains / strains ('pulled muscle')

Sunburn

Medical Conditions

TOTAL

Ankylosing spondylitis

Bell's palsy

Brain haemorrhage or tumor/tumour

Cervical spondylosis

Hematoma

Hepatitis (acute stage)

Fungal infection (large area)

Hemophilia

Infectious diseases (e.g. common cold, flu, meningitis)

Impetigo (not yet medically treated or sores still weeping)

Kidney infections, stones or failure

Meningitis

Migraine (active episode right now)

Osteoporosis

Osteomalacia

Paget's disease

Rickets

Scabies

Whiplash (recent)

MEDICAL PERMISSION

ANY UNLISTED MEDICAL CONDITION

Arthritis (e.g. osteoarthritis, rheumatoid arthritis)

Cancer

Cardiovascular conditions (e.g. thrombosis, phlebitis, hypertension, hypotension, any heart condition, recent stroke)

Cirrhosis of liver (advanced)

Edema / oedema

Emphysema / COPD

Epilepsy

Diabetes

Gastric ulcers

Inflamed nerve

Lower back pain / lumbago

Multiple sclerosis

Muscular disorders (e.g. muscular dystrophy, myasthenia gravis)

Nervous system dysfunction (e.g. muscular sclerosis, Parkinson's disease, motor neurone disease)

Neurological conditions (e.g. dementia, severe autism, severe learning difficulties)

Parkinson's disease

Postural deformities

Respiratory infection (except chronic sinusitis)

Rheumatism

Slipped disk / disc

Spastic conditions

Stroke (recent or not yet fully recovered)

Transient ischemic attack (TIA)

Tuberculosis

Unlisted bone disease

Unlisted skin disease

Whiplash (not recent)

LOCAL

Arthritis

Athlete's foot

Boils and carbuncles

Bursitis (acute)

Cold sores

Cramps (acute & severe)

Endometriosis

Fibrosis

Fractures

Fungal infections (small area)

Gall stones

Goitre

Gout

Hernia

Hormonal implants

Impetigo (untreated or not yet recovering)

Pelvis inflammatory infection

Prolapsed uterus / vagina

Scar tissue (recent or not yet 100% formed)

Shin splints (acute or severe)

Shingles

Tendonitis (acute)

Trigeminal neuralgia (acute)

Varicose veins

Warts

I, the client, declare that all of the details | have provided on this form are true and accurate. | understand this information is vital for my own health and safety. | agree to update the practitioner if my health situation changes before any future treatments. | understand my information will be kept private, shared only with a teacher for certification purposes.

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Medical Circumstances

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MEDICAL PERMISSION

LOCAL

Medical Conditions

TOTAL

MEDICAL PERMISSION

LOCAL

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