Initial Consultation Form | Jessielilytherapies

1. What is your main reason for booking the treatment?

2.Do you have any medical conditions? please can you list them and how they affect you?

3.Are you taking any medication? if yes, what are you taking and how do they effect you?

4.Have you had accidents, broken bones or operations?

5.Are you seeing a doctor/physio/chiropractor or a osteopath?

6. Females only- are you pregnant? if so, how many weeks are you?

9. Where on your body do you feel the pain?

10. When did the pain start? what do you think caused it?

11. What makes it feel better?

12. Whats makes it feel worse?

14. How has your general health been over the month? energy level, energised or tired. feeling tip top or under the weather?

15. How is your sleep?

16. What is your day to day life like? work, exercise, children, hobbies, are always on the go/ busy, or take things as they come/ chilled?

Where do you feel stress in your body?

Anything else you would like to add?