07942 310 852 info@garethwilkins.co.uk

Client information sheet

Marital status

Do you have any children?

What age range?

Permission to contact GP

How severe do you consider your health condition to be?

How successful were they?

What is your consumption of water per day? (Not including fruit juice, soft drinks, herbal teas, tea & coffee)

What are your bowel movements?

How often do you exercise?

Do you smoke?

Do you use orthotic appliances in your shoes?

Your menstrual cycle is:

I declare that the information that I have given is correct and as far as I am aware I can undertake the treatment without any adverse effects. I have been fully informed about the contract-indications and I am therefore willing to proceed with the treatment.

13 + 7 =