Client Wellness Form - Flexii Studio

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Client Wellness Form

All Clients are required to complete our Wellness Form prior to their first visit.

Flexii Wellness Form (#4)

Client First Name

Client Last Name

Date of birth

Gender

Email

Home Tel No.

Mobile No.

Work Tel No.

Home Address

Street

Town

Post Code

Doctors Details

Please complete all information requested.

GP Name

Practice Name

Practice Address

Street

Town

Post Code

Medical Information

Please complete the following section in full.
It is very important that we are aware if you are experiencing any of the following Conditions.

Lower Back Pain

Yes

No

Additional Information

Pelvic Pain

Yes

No

Additional Information

Any other Spinal Condition

Yes

No

Additional Information

Other Joint Conditions

Yes

No

Additional Information

Heart Issues

Yes

No

Additional Information

High/Low Blood Pressure

Yes

No

Additional Information

Epilepsy (Grand Mal Seizures).

Yes

No

Additional Information

Asthma/Lung Conditions

Yes

No

Additional Information

Diabetes

Yes

No

Additional Information

Are you pregnant?

Yes

No

Additional Information

Cancer

Yes

No

Additional Information

Have you had a Stroke?

Yes

No

Additional Information

If you are pregnant, How may weeks along are you?

If you have had any recent surgery or other medical conditions not mentioned above? Please provide details below

Client Consent

Please read the following section in full

Please Note

Signed

Date

Site Contents

About Flexii
Our Services
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Address

160 High Street.
London Coney,
AL2 1QF

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About Flexii
Our Services
Book a Session
Client Wellness Form
Make Contact