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Chloe's Annex
Skin Treatments & Massage
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Massage Therapy Consultation
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Address
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Email
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D.O.B
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Do you have any allegies
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If yes please state allergies below
What pressure do you prefer
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Light
Medium
Deep
List your areas of discomfort or pain if any
What are your goals for this treatment session
Have you ever had any surgery
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Give details below
Please tick any of the below that apply to you
Cancer
Arthritis
Diabetes
High/Low Blood Pressure
Numbness
Joint replacement
Sprains or strains
Neuropathy
Metal plates in treatment area
Fibromyalgia
Deep vein thrombosis
Kidney Dysfunction
Liver condition
Blot clots
Epilepsy
Muscle paralysis
Tumours
List any medication you take
Do you have any conditons not listed above
*
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Yes
No
If yes disclose condition below
I confirm all of the above details are correct
Massage Therapy Consultation
First name
Last name
Address
Address
Post Code
Phone
Emergency Contact Name
D.O.B
Email
Emergency Contact Number
Occupation
List any medication you take
Do you have any allegies
*
Required
Yes
No
If yes please state allergies below
Could you be pregnant
*
Required
Yes
No
Are you currently under medical supervision or receiving other medical intervention, if yes please give further details.
Please tick any of the below that apply to you
Contagious skin disease
Cancer
Arthritis
Diabetes
High/Low Blood Pressure
Any area of numbness
Joint replacement
Sprains or strains
Sever varocous veins
Asthma
Medical odema
Metal plates in treatment area
Fibromyalgia
Deep vein thrombosis
Kidney Dysfunction
Liver condition
Epilepsy
Muscle paralysis
Tumours
Recent head / neck injury
Cardiovascular condition
Haemophilia
Osteoporosis
Psycohosis
Do you have any conditions not listed above? If so please give details below.
Have you had any recent injuries or medical procedures
What pressure do you prefer
*
Required
Light
Medium
Deep
Reson for your massage
*
Required
Relaxation
Specific problems
Both
List any areas of discomfort or pain
I confirm all of the above details are correct
Your Signature
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