Personal Details


    Please select which of the following we may contact you about *


    GP Details

    General Health

    Are you currently taking any medication or supplements? *

    Please provide details

    Do you have any allergies/intolerances? *

    Please provide details

    How often do you exercise?

    Do you follow a specific diet?

    Please specify

    Do you smoke?

    How often?

    Do you drink alcohol?

    How many units per week (average)?

    Massage Consultation

    Have you previously had a professional massage?

    What pressure do you prefer?

    When did you last receive a professional massage?

    Which treatment did you have?

    Are there any areas you do not want massaged?

    Please provide details

    What are your goals for this treatment session?

    Please answer Yes or No for the following questions.

    Please provide details for any questions that you answer Yes for at the end of this section.

    Do you have blood pressure issues? *
    Do you suffer from any heart disorders? *
    Do you have a pacemaker? *
    Do you have Epilepsy? *
    Do you have a history of Thrombosis? *
    Do you suffer from any nervous disorders? *
    Do you have any infectious diseases? *
    Do you have any severe bruising? *
    Do you have any recent scar tissue? *
    Have you suffered recently from haemorrhages? *
    Do you have varicose veins? *
    Do you suffer from swelling/oedema? *
    Do you have any fresh cuts/ abrasions? *
    Have you recently had any inoculations? *
    Do you suffer from Phlebitis? *
    Have you recently had any surgery? *
    Have you ever had, or do you have cancer? *
    Do you have diabetes? *
    Do you have osteoporosis? *
    Do you have Arthritis? *
    Do you have any back problems? *
    Do you suffer from frequent headaches? *
    Are any areas particularly sensitive to pressure? *
    Are you suffering from sunburn? *
    Do you have a trapped nerve? *

    If you have answered YES to any of the above questions, please provide further details here:

    Any additional notes/comments:

    Female Clients Only

    Is there a possibility you may be pregnant?
    Are you breastfeeding?

    Consent

    I declare that the information I have given is true and correct as far as I am aware. I confirm that I can undertake the treatment explained to me by this therapist without any adverse effects. I have been fully informed about possible contraindications, and am willing to proceed. I understand that body massage is not a substitute, for medical advice and or treatment advised by my general medical practitioner.

    Client signature *