Name

 

Date:

Address

 

Postcode

Telephone:

Telephone/Mobile:

E mail:

Emergency Contact:

Male [ ]    Female [ ]

 

Date of Birth:

GP: Name

 

 

Surgery:      Phone:

Medication, prescribed and over the counter:

 

 

Supplements, if any:

Are you currently receiving treatment by a healthcare professional? If yes, please list:

 

 

What do you hope to gain from this treatment?

 

 

 

 

Lifestyle

Stress levels

-     At Home       +         -        At work      +

1 2 3 4 5 6 7 8 9 10        1 2 3 4 5 6 7 8 9 10

Do you eat a balanced diet? Do you have any specific dietary requirements?

 

 

What is your occupation?

(it does not need to be paid)

 

How much do you drink daily?

Water:                      Coffee      Alcohol

Tea:                          Other

How much free time do you have per week?

 

Do you smoke                    yes   no

How many per day?

What are your hobbies or creative interests?

 

Do you have any dietary problems?

(e.g. overeating, intolerances, bingeing)

 

How many hours sleep do you take?

Do you wake refreshed?

 

 

 

I declare that the information given on page 1 & 2 is true to the best of my knowledge, and that if any of the above circumstances were to change, I would inform you at my next treatment.  I agree to proceed with the consultation & treatment, and my participation in the treatment is my own choice. 

 

I agree to have my data held by Essential Wellbeing/Maike Dring for the purpose of proceeding and in connection with my treatments.  Information given will be treated with strictest confidentially and never shared, unless requested by the authorities to support the law. 

Data collected will be held in accordance with the General Data Protection Regulations 2018.

 

[_] Please tick          I wish to have my email added to the Newsletter e-mail list. E-mails contain tips about health issues,

                               special offers, information about treatments and classes offered by Essential Wellbeing. I understand

                               that I can withdraw my consent at any time, by contacting Essential Wellbeing.

 

Signed:                                                                                        Date:

Please type your name into the above space, to act as your signature in this electronic consultation form and email both pages back to me before the session.

 

This consultation & treatment is not intended as a substitute for medical treatment.

If in doubt, please consult your Doctor.

Location:

Dromore,

BT25 1NN,

Co. Down,

Northern Ireland.

Contact Us:

T: 044 7746114167

info@ewel.online

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