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Massage Therapy Consultation
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Have you ever had any surgery
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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
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List any medication you take
Do you have any conditons not listed above
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If yes disclose condition below
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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
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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
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Light
Medium
Deep
Reson for your massage
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Relaxation
Specific problems
Both
List any areas of discomfort or pain
I confirm all of the above details are correct
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