Name
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First Name
Last Name
Name as on your birth certificate
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Email
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Address
Telephone number
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Date of birth
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Medical information
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List any past surgery, serious illnesses, accidents or injuries with the dates and details.
List any medication or supplements you’re currently taking.
What are your energy levels like?
On a scale of 1 being extremely low to 10 bouncing off the walls.
Do you sleep well and wake refreshed?
Do you have any aches and pains?
If so, please detail what and where in the body.
How would you describe your current emotional state?
Feeling stresed, anxious, unhappy, angry etc.
What are your current stresses?
Please describe your diet.
Types of food you usually eat and when.
Are you sensitive to any foods?
Do you drink tea, coffee or energy drinks?
If so, how often?
How many litres of water do you drink daily?
Do you smoke or drink alcohol?
If so, how much and how often?
How many bowel movements do you have a day?
And what is the consistency of your stools?
Do you suffer from wind or bloating?
If so, do you experience it above or below the belly button?
How many times, roughly, do you urinate a day?
Female health
Is your menstrual cycle regular?
Do you experience PMS, heavy or painful periods?
Are you on contraception, if so which one?
Is there anything else you'd like to add or share?
What is the priority for your first session with Antonia?
What would you like to focus on?
Have you read my FAQs?
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Are you aware of my cancellation policy?
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With respect to my time and other clients who may have attended in your absence, I ask you to pay half the treatment fee if the cancellation takes place within 24 hours of your appointment.
Are you happy to be added to my email list?
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I confirm that I take full responsibility for my health and accept the outcomes of any advice or treatment that I receive from Antonia: I accept them as being complementary to, and not an alternative to, qualified professional medical treatments.
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