Sootheamuma Therapies - Health Questionnaire

First name

Last name

Date of birth

Day

Month

Year

Address

Phone number

Please give any relevant medical information that may affect your therapy.

Put N/A if not applicable

Please let us know what you would like to address with your therapy, e.g. help with an issue you are experiencing, relaxation, sleep etc.

If pregnant, please give details of any medical issues you have experienced during your pregnancy.

Put N/A if not applicable

Please give details of how you birthed any previous babies and if you had any issue with your postnatal recovery.

Put N/A if not applicable

How is your sleep?

Put N/A if not applicable

How would you rate your stress levels?

High

Average

Low

Do you have any allergies or sensitivities? If yes please give details below.

Put N/A if not applicable

Are you on any regular medication? Please give details below

Put N/A if not applicable

I confirm to the best of my knowledge that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment.

I understand that information is held securely and confidentially and is only used to arrange and plan my treatment. All records will be kept for a maximum of seven years and will destroyed/deleted immediately upon request

Health Questionnaire