New Client Medical Consent Full name Address Home tel. # Mobile Email Medical History Prescribed Medication YesNo Skin diseases or infections. YesNo Surgery (past 6 months) YesNo Pregnancy. YesNo Heart Conditions YesNo Respiratory Conditions. YesNo Immune Deficiency. YesNo Diabetes/Epilepsy. YesNo High/Low Blood Pressure. YesNo Cardiovascular Disease. YesNo HIV Positive YesNo Cancer or undergoing Treatment. YesNo Allergy to any treatment or products YesNo Other Ailments. YesNo Covid-19 Are you currently suspected of Covid symptoms? YesNo Have you been in contact with someone suspected or confirmed of having Covid-19. YesNo Recent Cough or any respiratory signs within the last 14 days YesNo Fever/High Temperature within the last 14 days YesNo Are you over 70 years? YesNo This data may be held electronically by Cranwell House with your permission YesNo I give Cranwell House permission to contact me by telephone or email YesNo I certify that the information I have given is correct Date