PERSONAL DETAILS

Name Date of Birth

Occupation Male Female

Home Address

Postcode Email

Home Telephone Mobile

Height Weight

Marital Status Children

Are you pregnant?

Yes No Due date:

Doctor’s Name Doctor’s Address Orthotics worn?

CONTRA INDICATIONS: (For Practitioner Use)

PREVIOUS ACCIDENTS/INJURY/ANY SERIOUS ILLNESSES OR OPERATIONS?

PREVIOUS PREGNANCIES – HOW DID YOU CARRY/BIRTH/PROBLEM(S) AFTER?

REASON FOR TREATMENT

ARE YOU CURRENTLY UNDER ADVICE OR TREATMENT FROM ANY OTHER HEALTH PROFESSIONALS?

Yes No

CLIENT RECORD/MEDICAL INFORMATION

Stephan J. Grabner – Amatsu Amatsu Practitioner Level1 MBRCP AMATI UK

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Referrals (For Practitioner Use)

From:

Sent letter to Doctor/Other re Client?

Attached to Client records

DO YOU HAVE PROBLEMS WITH, OR SUFFER FROM, ANY OF THE FOLLOWING? * Select Yes or No

MUSCULAR/SKELETAL NERVOUS SYSTEM CIRCULATORY Neck pain Sensitivity Heart Joint problems Migraine Blood Pressure Skeletal disorders Tension Fluid Retention Have you broken any bones? Headaches Tired Legs/Varicose

Veins Stress Cellulite

Knee replacement/pain Depression Circulation problems Upper/middle/lower back pain Pins and needles Cardiac problems

Other joint replacement Numbness Arteriosclerosis

Dizziness Valve replacement

DIGESTIVE GYNAECOLOGICAL IMMUNE SYSTEM Constipation Irregular periods Prone to infection Bloating PMT Sore throat Liver/Gall Bladder Menopause Colds Stomach HRT/Pill Chest Bowel problems Coil Sinuses

Hormonal Problems Skin problems

KIDNEY PROBLEMS Cold hands and feet Urinary problems

PRE-EXISTING CONDITIONS Rheumatism Diabetes Epilepsy Insomnia Stroke Asthma Cancer IBS Aortic aneurysm Deep Vein thrombosis Eczema Hay fever Tinnitus Psoriasis

No Yes NoYes

Stephan J. Grabner – Amatsu Amatsu Practitioner Level1 MBRCP AMATI UK

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IF YOU ARE CURRENTLY TAKING ANY MEDICATION, STATE BELOW WHICH MEDICATION AND WHAT YOU ARE TAKING IT FOR.

Hip replacement/pain

OTHER PROBLEMS/PRE-EXISTING CONDITIONS

YOUR LIFESTYLE How would you describe it? Relaxed Stressful Do you smoke/Have you ever smoked? Yes No Do you have time for regular exercise? Yes No Do you sleep well? Yes No Do you have time for yourself? Yes No Out of 10, how do you feel today? /10

DIET AND HYDRATION Do you eat a balanced diet? Yes No What is your daily intake of: (glasses/cups per day)

Water Tea Alcohol Coffee

Other

DO YOU HAVE ANY FOOD INTOLERANCES/ALLERGIES?

FURTHER DETAILS:

Stephan J. Grabner – Amatsu Amatsu Practitioner Level1 MBRCP AMATI UK

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ORIGINAL PROBLEM

Annotate discomfort/pain/problem

area

HOW LONG HAVE YOU HAD IT?

WHEN IS THE PROBLEM NOTICED?

WHAT MAKES IT WORSE?

WHAT MAKES IT BETTER?

Stephan J. Grabner – Amatsu Amatsu Practitioner Level1 MBRCP AMATI UK

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STATEMENT AND CONSENT OF CLIENT. DATA PROTECTION AND CLIENT CONFIDENTIALITY.

Client signature:

Please print name:

Date:

I declare that all the above given information is true and to the best of my knowledge. I confirm that I do not have any infectious disease and I agree to inform the practitioner should my health condition change or deteriorate.

I am aware that Amatsu does not replace diagnostic test and treatments available from my Doctor, the National Health Service or private medical care. I agree to retain my Doctor as my principal healthcare provider, consulting them as appropriate. I understand that I must consult with my Doctor before reducing or withdrawing any prescribed medication.

I understand that Amatsu uses touch and mobilisation. I consent to the Practitioner holding and moving my body to facilitate the treatment.

I agree that Stephan J. Grabner, in accordance with the Data Protection Act 1998 may hold and process the personal data in this form and any other data relating to my treatment. All information will be strictly private and confidential. Should consultation or referral be necessary, the Practitioner will obtain the client’s permission before disclosing any information.

I understand that failure to keep an appointment or provide more than 48 hours notification of cancellation will result in the full fee being charged.

Stephan J. Grabner – Amatsu Amatsu Practitioner Level1 MBRCP AMATI UK

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