top of page
Home
About
Jikiden Reiki
Yoga
BOOK ONLINE
Forms
Contact
More
Use tab to navigate through the menu items.
Reiki Health Questions:
Lifestyle Consultation Form
First name
*
Last name
*
Email
*
Phone
*
Address
*
Occupation
*
Birthday
*
Day
Month
Year
Jikiden Reiki is a hands on treatment do you consent to this?
*
Yes
No
Are you pregnant?
*
Yes
No
If yes how many weeks?
Please tick the boxes that are relevant for you.
*
Stress
Headache/migraine
Sleep Problems
Depression
ME/Glandular fever
Diabetes
Glandular Condition
Sinus Condition
Asthma/Bronchitis
Aches/Pains
Arthritis
Broken bones
Osteoporosis
Renal disorder
Liver Disorder
Blood pressure (high/low)
Heart condition
Oedema/Fluid retention
Constipation/Diarrhoea
IBS
PMT/Menstrual conditions
Menopausal symtoms/HRT
Herpes/cold sore
Eczema
Recent Surgery
Allergies/Hay fever
Cancer
N/A
Other
Are there any other medical conditions we should know about?
*
Are you taking any prescribed medication? If yes please give details.
*
Are you currently receiving any treatment from a GP/health professional?
*
What is the reason for your visit?
*
Submit
bottom of page