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Medical Consultation Form

Thank you for booking a treatment with Amaya Healing! So that we may offer you the best service, please could you complete and submit the medical form below, at least 48 hours prior to your appointment.

All information will be kept PRIVATE and CONFIDENTIAL

Health declaration

Please fill out the following form.

First name*

Last name*

Email*

Address*

GP Name*

GP Address*

GP Telephone Number*

Emergency Contact Name*

Emergency Contact - Telephone*

Emergency Contact - Relationship*

What is your preferred method of communication? *

Date of birth*

Day

Month

Year

How would you describe your general health?

Please provide details of any surgery / operations that you've had in the last 5 years. *

Please provide details of any implants / pins / pacemaker / piercings etc that you have.*

Please give details of any cosmetic procedures, including botox, fillers etc. Which you have had WITHIN THE LAST TWO WEEKS.*

Do you suffer from a low immune system?*

Are you prone to infections and frequent coughs, colds, sore throats? *

How good would you say your digestive system is?*

Do you experience Muscular / Skeletal problems?*

Do you suffer with joint or muscular aches and pains or back issues?*

Do you suffer with tension headaches or migraines?*

Do you have problems with circulation? Heart, blood pressure, cold hands and feet?*

Do you have Gynaecological issues?*

Are you pregnant or trying to conceive? *

Do you suffer with any of the following?*

Epilepsy

Migraine

Tension

Stress

Depression

Anxiety

Shortness of Breath

Wheezing

Coughing

None

Other

What is your skin type? Dry, Oil, Combination, Sensitive, Dehydrated.*

Do you suffer / have you suffered from: Dermatitus, Acne, Eczema, Rosacea, Psoriasis, Allergies, Hay Fever, Skin Cancer? *

Please list your current medications and supplements. Including name and dosage.*

Is there anything else that your therapist should be aware of before proceeding with your treatment?*

I certify that the information provided is true and accurate to the best of my knowledge and that relevant consent has been obtained from my GP. I understand that the Therapist will not be liable for any incidentals that may occur as a result of any omissions or undisclosed information.

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