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CLIENT PRE-CONSULTATION FORM

If you have not already done so, please complete this form in as much detail as possible so that we can get a good idea of your overall state of health and wellbeing. Helen will go through this pre-consultation form with you at the beginning of your appointment. Please note your records will be confidential unless you have given express permission for Helen to share information with a friend, relative or colleague in the holistic health space.

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PERSONAL DETAILS

Full Name *

Email Address *

Phone Number *

Date of Birth

Address

Emergency Contact Name

Emergency Contact Number

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CONSULTATION DETAILS

What is the main reason for booking this consultation?

What are your main health concerns at present?

How long have you been experiencing these concerns?

Have you received a diagnosis from a doctor or specialist?

Yes No

If yes, please provide details:

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CURRENT HEALTH STATUS

How would you describe your current overall health?

Excellent Good Fair Poor Very poor

How would you describe your current energy levels?

Very high Good Moderate Low Very low

How would you describe your current stress levels?

Very low Low Moderate High Very high

How would you describe your sleep?

Excellent Good Disturbed Poor Very poor

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CURRENT SYMPTOMS

Please tick any symptoms you are currently experiencing:

Please give more details about your symptoms:

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MEDICAL HISTORY

Do you have any current or past medical conditions?

Yes No

If yes, please provide details:

Have you ever had surgery?

Yes No

If yes, please provide details:

Are you currently under the care of a doctor, consultant, specialist, or other healthcare professional?

Yes No

If yes, please provide details:

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MEDICATIONS

Are you currently taking any prescribed medication?

Yes No

If yes, please list the medication, dosage, and reason for taking it:

Are you currently taking over-the-counter medication?

Yes No

If yes, please provide details:

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SUPPLEMENTS AND HERBAL PRODUCTS

Are you currently taking any supplements, herbs, vitamins, minerals, or natural remedies?

Yes No

If yes, please list everything you are currently taking:

Have you ever had a reaction to herbs, supplements, medication, or foods?

Yes No

If yes, please provide details:

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ALLERGIES AND INTOLERANCES

Do you have any known allergies?

Yes No

If yes, please list them:

Do you have any food intolerances or sensitivities?

Yes No

If yes, please list them:

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DIGESTIVE HEALTH

How often do you have a bowel movement?

More than once daily Once daily Every other day 2–3 times per week Less than 2 times per week

Do you experience any of the following?

Bloating Gas Constipation Diarrhoea Acid reflux Nausea Stomach pain Food sensitivities None of the above

Please provide further details:

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DIET AND NUTRITION

How would you describe your current diet?

Very healthy Fairly healthy Mixed Poor Very poor

How much water do you drink daily?

Less than 500ml 500ml–1 litre 1–1.5 litres 1.5–2 litres More than 2 litres

Do you consume any of the following regularly?

Coffee Tea Alcohol Fizzy drinks Energy drinks Processed foods Sugary foods Fast food None of the above

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LIFESTYLE

How often do you exercise?

Daily Several times per week Once per week Occasionally Rarely or never

What type of exercise do you do?

Do you smoke or vape?

Yes No Occasionally

Do you drink alcohol?

Yes No Occasionally

How would you describe your emotional wellbeing at present?

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WOMEN’S HEALTH, IF APPLICABLE

Are you currently menstruating?

Yes No Not applicable

Are your periods regular?

Yes No Not applicable

Please provide further details:

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GOALS AND EXPECTATIONS

What are your main health goals?

What would you most like support with during your consultation?

Have you worked with a holistic health practitioner before?

Yes No

If yes, please provide details:

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PERMISSION AND CONFIDENTIALITY

I understand that the information I provide will be kept confidential unless I give express permission for Helen to share information with a friend, relative, colleague, or another practitioner in the holistic health space.

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I agree

Do you give permission for Helen to contact you regarding your consultation and health support?

Yes No

Client Signature

Date