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Woodland Elements - Tuning Fork Therapy
Initial Consultation Form
Thank you for completing this questionnaire so that I can understand more about your needs and how to help you move towards improved health with Tuning Fork
Therapy.
About You
*
Indicates required field
Name
*
First
Last
Date of birth
*
Age
*
Phone Number
*
Mobile Phone Number
*
Email
*
Address
*
occupation
*
In case of emergency
name of person to contact in an emergency
*
emergency contact phone number
*
Do you live alone
*
Yes
No
Doctors Surgery
*
I ask for these details and permission to contact these people ONLY in case of emergency. I will not use them for any other purpose.
Your Experience
What current issues/ symptoms would you like to focus on (physical / mental / emotional)?
*
How did you hear about this therapy with me?
*
What would you like to gain from your session(s)?
*
Medical History
Please tick any of the boxes that apply to you and give more details in the box below
*
Adverse reaction to a previous therapy / treatment
Allergies
Anxiety
Arthritis - osteoarthritis
Arthritis - rheumatoid
Asthma
Auto-immune disorder (inc ME/MS/Lupis)
Balance issues
Blood pressure - high
Blood pressure - low
Breathing problems
Cancer
Depression
Diabetes
Digestive disorders or abdominal issues
Epilepsy
Heart condition
Joint problems
Long COVID
Migraine / headaches
Osteoporosis / osteopenia
Perimenopause / menopause
PTSD
Recent fracture
Recent surgery
Recent vaccinations (within last 7 days)
Sensory disorder affecting eyes or ears
Stroke
Thyroid issues
Thrombosis / embolism
Varicose veins / phlebitis
Please list any medication you are taking and why
*
Are you / have you recently been pregnant?
*
Yes
No
any other issues and further information
*
Have you been fitted with a pacemaker / vagal nerve stimulator / deep brain stimulator?
*
Yes
No
please give details
*
Disclaimer
By submitting this form, you are confirming that the contents are true and accurate to the best of your knowledge.
Please notify me of any changes to your responses in this health form before any sessions.
As a Tuning Fork Sound Practitioner, I am not qualified to diagnose any medical condition in the same way as a doctor/physician. My opinion is that of a holistic, complementary and alternative therapist and my professional opinions, advice, examinations and recommendations do NOT constitute the medical advice of a doctor/physician.
I confirm I have read the disclaimer
*
Yes
In order to comply with GDPR, it is necessary for me to check whether or not you are happy for me to retain your contact details, and to send you information that I think may be useful to you, including training and events, and relevant updates. I only hold information when it is necessary to do so and where you have given me permission to do so.
Please note all information collected on this registration form is treated as confidential and will not be shared with a third party. Data collected on this form is kept securely. Your data is kept for 7 years after your last session with me, as stipulated by my insurance company.
I agree to receiving newsletters from Woodland Elements, I understand I can opt out at any time
*
Yes
No
Submit
Home
Yoga
Book Now
Yoga Classes & Workshops
>
Watch Anytime
>
Dru Yoga Directory
Shakti Flow Directory
Journey through the Chakras
Customise Your Yoga
Yoga is for Everyone
>
Dru Yoga
Shakti Dance
Sound
Book Sound
Blog
About
Small Print
>
Privacy & Cookies
Safety
Terms and Conditions
Get in Touch
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