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CASE HISTORY FORM Please use this form to report particulary interesting Case Histories, anecodotes or other events that have occurred to you or your clients while practicing VRT. We may include these in subsequent newsletter. It is always interesting to know how others are progressing. Either print this form and fill it in with the details, or copy it into a word processor or email and fill in the appropriate details and email to us at contact@boothvrt.com Please find time to let me know of any particularly good result(s) with VRT as this will help our research and some of these details can be shared in future newsletters. You need only write a few lines but I may contact you at later date if a little more information is required. Very occasionally we are asked by journalists, professional bodies or the medical profession to quote a case history. Please indicate below how you wish to be quoted - it can be anonymous if you wish. Thank you. Please list the following: Condition treated _______________________________________________________________ Client: Male / Female (please circle) Age ______________________Duration of illness (approx.) _______________. No. of VRT/reflexology treatments ________ Aim of VRT treatment ________________________________________________________ __________________________________________________________________________ Result (continue overleaf if necessary) __________________________________________ __________________________________________________________________________ Any contraindications? ______________________________________________________ __________________________________________________________________________ Other comments ____________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ (If you wish, send more than one case history/anecdote on a separate page if necessary) Name _____________________________________________________________________ Address ___________________________________________________________________ ______________________________________________________.Postal code_________ Tel. no.______________Fax no________________email ___________________________ Are you willing to have this case history quoted? Yes / No (please circle) If so, do you wish to be quoted by Name / Initials / Anonymously (please circle) Please send to: Results - Booth VRT Ltd.Suite 205, 60 Westbury Hill, Westbury on Trym, Bristol. BS9 3UJ, UK. Tel/Fax: (0117)962 6746 Email: contact@boothvrt.com
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