Janis@jsm-therapies.co.uk
		Consultation Form   Name:   Address and Telephone no:   Date of birth:   Occupation:   Dr's name and address:   LIFESTYLE:  1   Are your energy levels ?: High Average Low   Are your stress levels ?: High Average Low   Do you have a balanced diet ?: Yes No   What sports and hobbies do you participate in ?:   MEDICAL:  2   Do you suffer with, or have you ever suffered from:  2   any of the following ?:  2   High/Low blood pressure: Yes No   Thrombosis: Yes No   Cancer: Yes No   Epilepsy: Yes No   Diabetes: Yes No   Skin disorders: Yes No   Recent fractures/sprains/strains: Yes No   Recent operations: Yes No   Allergies: Yes No   Auto Immune disorders: Yes No   Varicose veins: Yes No   Inflamation: Yes No   Nervous system disorders: Yes No   Cardiovascular disorders: Yes No   Are you pregnant: Yes No   Any recent head or neck Injuries: Yes No   Any other medical conditions:   If you have answered yes to any of the above:  3   can you please give details:   Please give details of current condition: