All about me!

Medication • Supplements • Remedies; strength, dose and No times / day

Specify allergen and reaction

Date of operation • Type of operation

Date of operation• Reason (fibroids) • Outcome (hysterectomy)

Date • injury • Outcome • especially injuries to sacrum & coccyx

Amounts: bread • milk • cereal • other

Amounts and type sandwiches – no. slices • rolls • fillings • cooked lunch – made up of

Amounts: protein • carbohydrate • fluids • sugars etc.

How often snack • binge • worst food item you eat • What food is your weakness • what triggers this?

How Many pregnancies have you had? Were any terminated? How many Births have you had? Were any premature? Please include dates

Spotting during pregnancy, Weak New-borns, Incompetent cervix?

During pregnancy? Labour, Birthing. Post Natal

Menstrual Problems, Medication she took whilst pregnant with you, Your birth trauma

Name of medication, Dose, Date started taking medication, Date stoped taking medication, Reason for stopping medication?

Who and outcome: Operation/Chemotherapy/Radiotherapy

Age died and cause of death of mother, grandmother, grandfather and any major illnesses they suffered from

Age died and cause of death of mother, grandmother, grandfather and any major illnesses they suffered from

No. of siblings. Age died and cause of death and any major illnesses they suffered from

Describe your exercise routine (Type & Frequency)

What is your opinion of yourself? Describe the most positive emotion you experience. When and where do you experience this emotion Describe the most negative emotion you experience. When and where do you experience this emotion?

I the above, have sought professional medical advice for my health, medical emergency, general health problems and diagnosis. My Jacksfeet therapist may recommend that I see a licensed physician or health care professional. For any physical, psychological, emotional, mental ailment I may have if they have concerns. This treatment does not take the place of medical care. The intentions to help promote balance and harmony within the body. Through, stimulating blood, lymphatic and energy flow to and from the organs and within the bodies systems. Increase the natural release of toxins and their excretion from the body.  This will help to maintain the body’s organs optimum functioning. Consequently, I acknowledge that as a client of Jacksfeet. I understand that during my treatment my therapist. 1 Does not diagnose medical illness, disease nor any other physical / mental illness. 2 They will neither prescribe medications nor perform medical procedures. 3 Give me prescribed substances. 4 Interfere with the treatment of a licensed medical professional. 5 Advise me to stop or discontinue any medicine / medical treatment I am undergoing. 6 Does not perform any spinal manipulations. 7 Work will complement any medical or psychological care from the doctors and other healthcare professionals. 8 Gives me only research-based information. 9 Can give suggestions, information, teach techniques that improve health issues because they’re a qualified therapist and teacher. And it’s within their scope of practice. 10 Can blend oils and creams because they’re a qualified aromatherapist. 11 Aim of these treatments to experience complete relaxation. This works beneficial to the body in aiding healing. Therefore I do not hold Jacksfeet Therapists responsible for any post-treatment effects that arise after receiving this treatment.  I use all information and techniques from this treatment at my own discretion and risk. I accept that the therapist reserves the right to refuse to carry out any treatment which I have requested if in their professional opinion such a treatment is not suitable. I hereby conclude that the above information I have given to the best of my knowledge remains true and correct. I understand that Jacksfeet will keep all the information I have given safe and confidential and not used or passed onto anyone else. I receive treatments entirely my own risk and that my therapists accept no responsibility. I agree that in the case of a reaction, I will not hold the Jacksfeet therapists responsible in any way, I recognise that in writing my full name above it becomes an accepted digital signature consenting to receive this treatment and take full responsibility if any adverse reactions occur.

Medication • Supplements • Remedies; strength, dose and No times / day

Specify allergen and reaction

Date of operation • Type of operation

Date of operation• Reason (fibroids) • Outcome (hysterectomy)

Date • injury • Outcome • especially injuries to sacrum & coccyx

Amounts: bread • milk • cereal • other

Amounts and type sandwiches – no. slices • rolls • fillings • cooked lunch – made up of

Amounts: protein • carbohydrate • fluids • sugars etc.

How often snack • binge • worst food item you eat • What food is your weakness • what triggers this?

How Many pregnancies have you had? Were any terminated? How many Births have you had? Were any premature? Please include dates

Spotting during pregnancy, Weak New-borns, Incompetent cervix?

During pregnancy? Labour, Birthing. Post Natal

Menstrual Problems, Medication she took whilst pregnant with you, Your birth trauma

Name of medication, Dose, Date started taking medication, Date stoped taking medication, Reason for stopping medication?

Who and outcome: Operation/Chemotherapy/Radiotherapy

Age died and cause of death of mother, grandmother, grandfather and any major illnesses they suffered from

Age died and cause of death of mother, grandmother, grandfather and any major illnesses they suffered from

No. of siblings. Age died and cause of death and any major illnesses they suffered from

Describe your exercise routine (Type & Frequency)

What is your opinion of yourself? Describe the most positive emotion you experience. When and where do you experience this emotion Describe the most negative emotion you experience. When and where do you experience this emotion?

I the above, have sought professional medical advice for my health, medical emergency, general health problems and diagnosis. My Jacksfeet therapist may recommend that I see a licensed physician or health care professional. For any physical, psychological, emotional, mental ailment I may have if they have concerns. This treatment does not take the place of medical care. The intentions to help promote balance and harmony within the body. Through, stimulating blood, lymphatic and energy flow to and from the organs and within the bodies systems. Increase the natural release of toxins and their excretion from the body.  This will help to maintain the body’s organs optimum functioning. Consequently, I acknowledge that as a client of Jacksfeet. I understand that during my treatment my therapist. 1 Does not diagnose medical illness, disease nor any other physical / mental illness. 2 They will neither prescribe medications nor perform medical procedures. 3 Give me prescribed substances. 4 Interfere with the treatment of a licensed medical professional. 5 Advise me to stop or discontinue any medicine / medical treatment I am undergoing. 6 Does not perform any spinal manipulations. 7 Work will complement any medical or psychological care from the doctors and other healthcare professionals. 8 Gives me only research-based information. 9 Can give suggestions, information, teach techniques that improve health issues because they’re a qualified therapist and teacher. And it’s within their scope of practice. 10 Can blend oils and creams because they’re a qualified aromatherapist. 11 Aim of these treatments to experience complete relaxation. This works beneficial to the body in aiding healing. Therefore I do not hold Jacksfeet Therapists responsible for any post-treatment effects that arise after receiving this treatment.  I use all information and techniques from this treatment at my own discretion and risk. I accept that the therapist reserves the right to refuse to carry out any treatment which I have requested if in their professional opinion such a treatment is not suitable. I hereby conclude that the above information I have given to the best of my knowledge remains true and correct. I understand that Jacksfeet will keep all the information I have given safe and confidential and not used or passed onto anyone else. I receive treatments entirely my own risk and that my therapists accept no responsibility. I agree that in the case of a reaction, I will not hold the Jacksfeet therapists responsible in any way, I recognise that in writing my full name above it becomes an accepted digital signature consenting to receive this treatment and take full responsibility if any adverse reactions occur.