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Children's Author & Family Wellness Leader

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Health Consultation

If you have a booking with me for any of my wellness 1:1 session, please complete this confidential consultation. This will allow myself to provide a tailored wellbeing service for your personal needs.

Health Declaration

Please fill out the following form
in order to enjoy your bespoke healing/wellbeing sessions

First name

Address

Last name

Date of Birth

GP Name, Address, Telephone Number

Please tick health conditions which apply to you:

High Cholesterol

High / Low Blood Pressure

Autoimmune Diseases

Arthritis

Epilepsy

Depression

Anxiety

Lympthedema

Meonpausal

Pregnancy

Back problems

Circulatory problems

History of Thrombosis

Cancer

Diabeties

Bruising

Hormonal Imbalances

Urinary problems

Varocoise veins

Please provide addititional details for medical conditions and history

Please share detail for: - Daily / Weekly routines - Water Consumption, Sleep Quality, Exercise, Alcohol consumptionn

Select a date

"I consent to details of my medical and treatment records being kept safely and securely to meet current GDPR rules."(Please note I am unable to treat you without your consen

I want to subscribe to the newsletter to receive details of wellness tips and offers. I understand that I can unsubscribe at any time

Thanks for submitting!

Thank you

I look forward to welcoming you.

Please ensure you have saved your appointment time and location.

If you have any questions please email info@peaceandpresence.co.uk

2023 Louise Winstanley

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