Health Questionnaire and Consent Form

In order to prepare a treatment plan for you we need to collect some information. We ask that you complete this form before your first treatment so that we don’t take actual treatment time doing so.

You can fill out the form below or, if you prefer, you can print out the form here.

 

* = mandatory field

 

Section One: Client Details

Name*

Address

Phone

Email*

Date of Birth:

G.P. Name:

G.P. Address:

G.P. Phone:

Description of usual work/hobbies:





Section Two: Health Questionnaire

Do you have any of the following conditions?

Headache?

 Yes No

Skin Problems?

 Yes No

Migraines?

 Yes No

Cancer?

 Yes No

Insomnia?

 Yes No

Digestion Problems?

 Yes No

Diabetes

 Yes No

Circulation Problems?

 Yes No

Epilepsy?

 Yes No

Varicose Veins / Thrombosis?

 Yes No

Allergies?

 Yes No

Pregnant / IUD?

 Yes No

High/Low Blood Pressure?

 Yes No

Digestion / Bowl problems?

 Yes No

Heartburn / Reflux?

 Yes No

Respiratory Problems?

 Yes No

Arteriosclerosis?

 Yes No

Stroke?

 Yes No

Bowel Problems?

 Yes No

Urinary Problems?

 Yes No

Hormonal Problems?

 Yes No


Please fill in as much detail on any condition you clicked yes


General Questions

What is the reason for needing Amatsu?

Have you consulted anyone about the above?

List all medication include prescribed self administered and recreational i.e. smoking:

How much water do you drink daily?

What is your tea / coffee intake per day?


Who referred you to the clinic?

Have you ever been in a car accident?


Specific Problem Details

Main Site : Where is the pain?

Aggravating Factors: What make it worse?

Relieving Factors: What makes it easier?

Character Type of pain? sharp/dull/intermitted/stabbing etc.

Onset: Start of onset?

Severity: Is your sleeping affected?

Duration: How long does the pain last for?

Radiation: Does the pain travel / Radiate?

Associated Magnifications: Any Bruising

Frequency: When does it occur?

Time: Time of occurrence?

List all operations and approximate date




Section Three: Statement and Consent of Client. Data Protection and Confidentiality.


I declare that all of the aforementioned information is true to the best of my knowledge. I confirm that I do not have any infectious disease and I agree to inform the practitioner should my health condition change or deteriorate.


I am aware that Amatsu does not replace diagnostic tests and treatments available from my Doctor or the HSE / private medical care. I agree to retain my Doctor as my principal healthcare provider, consulting with them as appropriate. I understand that I must consult with my Doctor before reducing or withdrawing any prescribed medication.


I understand that Amatsu uses touch and mobilisation. I consent to the Practitioner holding and moving my body to facilitate the treatment.


I agree that David McCarthy and Alan McCarthy, in accordance with the Data Protection Act 1998 may hold and process the personal data in this form and any further data relating to my treatment. All information will be treated as strictly private and confidential. Should consultation or referral be necessary, the Practitioner will obtain the client's permission before disclosing any information.


I understand that failure to keep an appointment or provide more than 24 hours notification of cancellation will result in the full fee being charged.


I Agree With The Above Statements