Chi Philosophy Consultation Form
Personal Details
Name:
Address:
Phone / Mobile:
Email:
Occupation:
Age:
 Date of Birth:
 Height:
Weight:
For female client:        Are you pregnant?
 Yes
 No
If yes, how many weeks?
Health Status
Which word best describes your state of health? Select an
option:
Operations / Injuries
Have you ever had any operations or bone fractures?
 Yes
 No
If yes, please give details:
Lifestyle
Do you smoke?
 Yes:
 No:
 If yes, how many per day?
What do you do to exercise and how often do you do it?
How easy do you find it to relax? Select and option:
How well do you sleep at night? Select an option:
On average how many hours do you sleep a night? Select and option:
Diet
Is your diet well balanced containing fruit, vegetables, starch and meat / fish:
 Yes
 No
Do you have 3 meals a day?
 Yes
 No
How many do you have of the following a day?
 Tea
 Coffee
 Squash
Fizzy Drinks
 Water
 Herbal Tea
A Walk Through Your Body Systmems

Skin
Select any conditions that are relevant (multiple selections are possible by
holding down the control key and clicking on the option to select)
Further details
Muscular / Skeletal
Select any conditions that are relevant (multiple selections are possible by
holding down the control key and clicking on the option to select)
Further details
Digestive
Select any conditions that are relevant (multiple selections are possible by
holding down the control key and clicking on the option to select)
Further details
Circulation
Select any conditions that are relevant (multiple selections are possible by
holding down the control key and clicking on the option to select)
Further details
Nervous System
Select any conditions that are relevant (multiple selections are possible by
holding down the control key and clicking on the option to select)
Further Detials
Immune System
Select any conditions that are relevant ( multiple selections are possible by
holding down the control key and clicking on the option to select)
Further Details
The Chi Philosophy Experience
What treatments have you had in the past and which one/ ones were your favourite?
Do you prefer deep pressure during the treatment or would your rather the pressure was light and relaxing?
Do you like music during your treatment and if so, would you be interested in choosing from a selection of play-lists including jazz, tribal,
alternative, easy listening, classical?