This client has reported allergies. Please review before treatment.
- Epilepsy
Please acknowledge the allergy or risk alert above before opening photos, files, or review notes.
Personal details
- Name
- Oliver Hughes
- oliver.hughes@example.test
- Phone
- 07700900128
- Date of birth
- 18/04/1995
- Address
- 5 Mill Road, Cambridge CB1 2JW
Medical history
Signature
Signed: 18 Aug 2026
Oliver Hughes
Client reports ongoing tension with no absolute contraindications declared. Review flagged items before treatment and confirm medication changes since the last visit.
Suggested follow-up questions
- Any changes to medication since your last visit?
- How has pain changed over the past week?
CliniForm AI summaries are generated from declared form answers only. Not medical advice — for practitioner review.
Personal Details
- First Name
- Oliver
- Surname
- Hughes
- Address
- 5 Mill Road, Cambridge CB1 2JW
- Phone
- 07700900128
- oliver.hughes@example.test
- Date of Birth
- 18/04/1995
- GP name & surgery
- Dr Bennett, Cambridge Health Centre
- Emergency contact name
- Lucy Hughes
- Emergency contact phone
- 07700900461
- Relationship to you
- Parent
Medical History — please tick any that apply:
- Selected options
- Epilepsy, Neck pain, Stress
Medications & Allergies
- Current medications (including dosage if known)
- Sertraline 50mg daily.
- Allergies — please list all known allergies
- No known allergies.
Lifestyle
- Occupation
- University lecturer
- How often do you exercise?
- Rarely
- Typical daily water intake
- 1.5–2 litres daily
Treatment Information
- Areas of tension or discomfort
- Prefers quiet room and advance appointment reminders.
- Pain scale (1 = no pain, 10 = worst pain)
- 6
- Previous massage experience
- See consultation notes on file.
- Anything else we should know before treatment?
- See consultation notes on file.
Treatment Consent
- I consent to receive the treatment discussed today and understand I may withdraw consent at any time.
- Yes
Data Protection (UK GDPR)
- I consent to my personal data being processed for the purposes of my treatment and care records, in accordance with UK GDPR.
- Yes
- How did you hear about us?
- GP recommendation
Client Signature
- Date
- 26/08/2026
Body diagram
Body map annotations
Signature
Signed: 18 Aug 2026
Photos & files
Attach consultation photos, skin analysis images, or documents.
Previous notes
| Date | Template | Service | Pain | Practitioner | Attachments | |
|---|---|---|---|---|---|---|
| No review notes for this period. | ||||||
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