Consultation form

Name
First Last
Date of Birth*
DD slash MM slash YYYY
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Phone*
Please provide a mobile number if possible
Email
General Consent*
By providing the information in this form I agree to its use for the express purpose of assessment and treatment by Catherine Franks (thebodytherapist). I understand that all information will be kept securely in electronic and/or print format and that it may be shared with a 3rd party ONLY with my explicit and written permission on each and any occasion. I am aware of my rights under the Data Protection Act and of Catherine Franks' privacy policy which can be found at www.thebodytherapist.co.uk/appointments/treatment-guidelines-and-covid-19-information/
Email consent
Please leave this tickbox blank if you do NOT wish to be added to my mailing list.
By providing my email address I agree to its use for communications including marketing from Catherine Franks (thebodytherapist). I acknowledge that my email address will never be shared with a 3rd party without my explicit consent and I have the option to unsubscribe at any time.
Occupation and main daily activities (exercise, hobbies, etc)
Medical History Section
Injuries, surgery and traumatic events*
Please list any injuries, surgery or serious illness/trauma experienced, including in childhood. You can add another row by clicking on the + sign.
Year/Age Event Additional comment
General health*
Tick any that are current or ongoing issues, or you have a history of, whether diagnosed or not
- Heart condition
- Circulatory condition
- Respiratory condition
- High/low blood pressure
- Thrombosis
- Dizziness or blackouts
- Epilepsy
- Diabetes
- Abdominal complaint
- Bowel complaint
- Urinary/kidney complaint
- Gynaecological complaint
- Skin disorder
- Auto-immune disease
- Allergy/intolerance (including coeliac disease)
- Neurological disorder (MS, stroke etc)
- Headache (including migraine)
- Dental or jaw issues
- Eye condition/visual disturbance
- Osteo-arthritis
- Widespread chronic pain
- Tinnitus
- Chronic fatigue
- Eating disorder
- Potentially fatal condition
- Smoker?
- Significantly over or underweight?
- None of the above
Current treatment
Give the name of any condition(s) you are currently receiving treatment for and medication prescribed
Section for women only
Number of pregnancies
Please enter a number from 0 to 12.
Number of live births
Please enter a number from 0 to 12.
Year of last birth/termination/miscarriage
Pregnancy complications
List any complications resulting from pregnancy or birth, including C-section
Treatment section
Primary reason for seeking treatment*
Give your PRIMARY reason for seeking treatment - include any relevant symptoms/diagnosis/previous treatment and outstanding referrals, also what relieves/exacerbates the issue
Other reasons for seeking treatment
Give any other issues you hope treatment will help with, including relevant symptoms/diagnosis/previous treatment
Other therapies
What (if any) other complementary therapies do you use/have you used?
Covid-19 section
I have, or think I might have had, Covid-19*
- Yes
- No
I have received one or more Covid-19 vaccinations*
- Yes
- No
I have read and understood thebodytherapist health guidelines*
- Yes
- Not yet
Additional information
Anything else?
Please write here anything else you think I should know
File Upload
Attach any documents or scans that you think would be useful for me to see
Drop files here or

Accepted file types: jpg, pdf, Max. file size: 128 MB, Max. files: 5.

When you click the Submit button the form will be emailed to me automatically.

The body therapist

Tel: 07748 637555
Email: catherine@thebodytherapist.co.uk

Year/Age	Event	Additional comment

Medical History Section

Section for women only

Treatment section

Covid-19 section

Additional information

The body therapist

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The body therapist

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