HOLISTIC REFLEXOLOGY

Hair Test Order Form

Health Questionnaire

Please describe conditions as fully as possible, indicating what makes it better (other than drugs) or worse – e.g. rubbing, heat, noise, light, lying, standing, weather, temperature.

Try to give dates and duration of any current or past physical and emotional problems so that a healing time line can be established.

All information is strictly confidential. If you are unhappy about giving precise details about certain events or problems in your life, it is helpful if you can indicate the type of emotion experienced at the time - e.g. anger, fear, grief.

Please ensure you answer every section and try to avoid words such as usual or normal

Any child under the age of 16 years must have this questionnaire authorised by their parent or guardian*.

Personal Details

Name
Date of Birth
Address 1
Address 2
Address 3
Post code
Country
Telephone No
email

General Health Details

Occupation
Hobbies / sports
Smoker
Alcohol consumption
Presenting condition
Date of first symptoms
Medical treatment
Current medication
Past medication
Vaccination history

Medical History

Headaches -
Where, when, description of pain
Scalp or hair problems
Eyes / Sight -
Glasses, discharges, dryness,
Ears / Hearing -
Discharges, pain, sounds
Nose / Sense of smell -
Discharges, sinuses, hay fever
Mouth / Taste -
Gums, tongue and coating, ulcers
Throat / Voice
Problems or sensations
Breathing / Chest -
Asthma, pain, sighing, yawning
Heart / blood pressure -
Palpitations, high / low BP
Appetite / Sensitivities -
Cravings, aversions, foods which aggravate
Typical days diet (be honest!)-
Breakfast
Lunch
Dinner
Snacks
Drinking habits -
Thirst and preferred drinks
Digestion -
Indigestion, heartburn, burping, pain
Bowels motions -
Frequency, hard/soft, colour, smell
Flatulence, bloating, piles, itching
Urine -
Smell, colour, frequency, pain
Sexual organs / libido / thrush-
Any discharges, soreness, pain
Menstruation / PMT -
Frequency, duration, flow, pain,
Pregnancy History
Breasts
Extremities / movement
Aches/ pains in arms, legs, back, neck
Condition of nails
Skin / eruptions -
Dry, itchy, greasy, eczema, acne, boils
Sleep Pattern / dreams -
Getting to sleep, sleep: sound / restless
Environmental effects -
Heat/cold, damp/dry, drafts, sun, open air, light, noise
Emotional -
Angry / irritable or emotional / weepy
Anxieties, fears, phobias
Confidence level
Past emotional upsets, traumas, deaths etc. and responses to them
Traumas -
Past operations, illnesses,
Accidents and responses to them.

Declaration

Name Signed
Date *Guardian

The above information is believed to be an accurate description of my current health. If client is under 16 years of age this must be signed by a parent or guardian.

Please send this questionnaire with a cheque for £40 in UK pounds sterling made payable to Cyla K. Higley

Results and remedies will normally be despatched within 10 working days.

Contact details

The hair test is designed to help you to identify and then assist you in resolving the root cause of your problem which also gives you back control over your health.

What will you receive?
Depending on your condition, using a kinesiology test to help your hair analysis, you may receive information relating to a basic food sensitivity test, vitamin and mineral requirements, organ imbalance, homeopathic remedies, Bach flower requirements, suggestions for structural corrections and chakra requirements.

The hair test allows everyone to receive a specific, individual and holistic treatment suggestion.

A variety of Natural Therapies may be suggested

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Including Homeopathy, Kinesiology and Reflexology
In Marlborough, Wiltshire