New Client Form & Health Questionnaire

Health & lifestyle questionnaire. Client code of care form & consent.

Emergency Contact name

Emergency contact Phone Number

Medical History

Please answer the questions below.

Any serious Childhood illnesses:

Any chronic diagnosed conditions: (past / present) starting/ending date if applicable

Any past major surgeries

Anything else you think I should be aware of/Special requirements?

Current Health & Wellbeing

Any ongoing medical investigations/treatments?

Any recent or planned surgery?

Any recent accidents?

Any medication currently being used?

Are you pregnant, or trying to get pregnant (if applicable)?

Menstrual Cycle - if applicable

Lifestyle

Please provide as much information as you feel comfortable doing. This section is to give background on your general wellbeing and build a holistic picture of you, as a new client. Any information you share will be treated in the strictest of confidence and in line with GDPR regulations; and will be helpful to your therapist (and you) as a baseline to monitor your progress and any beneficial changes throughout the course of your treatments.

Diet/fluid intake (daily)

Estimated weekly alcohol intake (units or description)

Usual daily caffeine intake (number of drinks & time of last drink of the day)

Do you smoke or vape? If so, approximate number per day?

If not currently a smoker, have you ever been a regular smoker?

Relaxation (regularity, activities, priority)

Energy levels (0=very poor, 5=excellent) in the morning, afternoon, evening and at night.

Stress levels (0-5 as for previous question) around: home, work, social, health, financial, background.

Complementary therapies

Any past experience & about your forthcoming booking

Have you ever had Complementary Therapy treatment(s) before?

If so, when was your last session?

What are you hoping to get from your treatment at this time? (please select as many options as you like)

I want to subscribe to the mailing list.

I understand that Complementary Therapies are not a substitute for conventional medical treatment.

I understand that the information I have provided will all be treated in strict confidence, stored securely and treated in line with current GDPR legislation.

I am aware that I can request to see a copy of all records and notes held about me, and request corrections if they are incorrect.

I am aware that all personal and medical information provided by me to Ema Melanaphy will be used only for the purposes of my treatment by her, unless she has cause for concern about my safety or the safety of anyone else; in which case I understand that she may need to share my details with the appropriate authorities, as a legal and professional obligation.

I understand that these sessions will be at the rate quoted on the website at the time of booking, and have read and agree to the terms of the Cancellation and Privacy Policies (below).

Your Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Cancellation Policy

Cancellations made prior to 2 days before an appointment will be refunded in full.

Cancellations between 24-48 hours prior to an appointment will receive a 50% refund.

Cancellations from 24 hours before an appointment onwards, will incur the full charge (unless waived, at the therapist’s discretion).

Privacy Policy

The personal data I collect about you relates to your name, address, your health and history and treatments/treatment plan, as well as any recommendations or suggestions/information I may provide you, during the course of your treatments with me.

This data will be stored and used in accordance with GDPR regulations.

It will only be used by myself, for communication with you, and as part of my ongoing treatment of yourself, to record any changes to your health and wellbeing, and any relevant changes you make me aware of, which may occur during the course of your treatment.

You have the right to see these records at any time, and have the right to ask for it to be destroyed.

Should you have a complaint, you have the right to request contact details of the supervising authority/Association, to lodge this.