Consultation Form - Alex Everitt | Chiropractic & Sports Therapy

alex.everitt@aechiropractic.co.uk

07979 707 530

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Treatments
About
Reviews
FAQs
Contact
Book Online

Consultation Formhenry_goodger2023-01-29T14:53:51+00:00

First Name *

Last Name *

Email Address *

Client Address *

Telephone Number *

Occupation *

Sex *

Date of Birth *

GP Address *

Contraindications (please tick where appropriate)

Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.

Pregnancy

Cardio Vascular Conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)

Osteoporosis

Haemophilia

Any condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath , Chiropractor, Coach

Medical Oedema

Epilepsy

Any recent operations

Diabetes

Asthma

Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson's Disease, Motor Neurone Disease)

Kidney Infections

Whiplash

Slipped Disc

Acute Rheumatism

Taking prescribed medication

Contraindications that restrict treatment (please tick where appropriate)

Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner

Fever

Contagious or Infectious disease

Under the influence of recreational drugs and/or alcohol

Diarrhoea or vomiting

Skin Diseases

Undiagnosed lumps or swelling

Localised swelling

Inflammation

Varicose Veins

Pregnancy

Cuts

Bruises

Abrasions

Sunburn

Scar tissues (2 years for major operations & 6 months for small scar)

Hormonal Implants

Abdomen (first few days of menstruation depending on client)

Haemotoma

Hernia

Recent fractures (min 3 months)

Cervical Spondylitis

Gastric Ulcers

After a heavy meal

Written permission required by GP/Specialist (Separate form to be collected) *

Personal Information

Tel. 07979 707 530

alex.everitt@aechiropractic.co.uk

AE Chiropractic,
3, Cannon Court,
Newport Pagnell,
MK16 8ET

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