consultation form

Please only complete the consultation questionnaire once you have booked in with Marcos. Book directly by contacting Marcos here.

Name *

First

Last

Address

Telephone

Email *

Date of Birth

Occupation

Have you recently visited your GP or another alternative practitioner, and why?

Please give details of any medication you are currently on (inc.steroids, HRT etc.), and of any recent accidents/injuries/operations.

Health Disorders / Conditions / Symptoms

Hi / Lo blood pressure
Cancer
Respiratory Conditions
Heart Conditions
High Cholesterol
Thyroid
Thrombosis / Phlebitis
Digestive Problems
Stress
Emotional Problems
Depression
Insomnia
Migraine / Headaches
Backache
Diabetes
Epilepsy
Contagious Skin Conditions
Recent Pregnancy
Varicose Veins
Allergies
Poor Circulation
Kidney / Bladder
Arthritis / Rheumatism
Menstruation Problems
Infertility
Hormonal Problems
Fluid Retention
Cellulite
Overweight
Other pain

Any other disorders / conditions / symptoms not mentioned above and any other information you would like Wild Wood Therapies to know in relation to your health:

Please confirm your reason for booking a treatment with Wild Wood Therapies?

Date

Signature

Comment

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