Client Consultation Form
Full Name
*
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Mobile is preferd
Email
*
example@example.com
GP's Name or surgery
How is your general state of health:
What's your occupation?
Do you excersise regualary? How often?
Describe your stress level
Are you currently taking any medication?
*
Yes
No
If yes, give details below
Check any conditions that apply to you:
Less severe lung condition (asthma)
Severe lung condition i.e. cystic fibrosis or severe asthma/COPD
Cardio-vascular or any heart conditions (thrombosis, phlebitis, hypertension)
Diabetes
Hypertension
Psychiatric/nervous disorder
Any skin condition
High or low blood pressure
Circulatory condition
Blood clots
Arthritus or any bone/joint condition
Tendonitis
Lymphatic condition
Varicose vains
Headaches/migranes
Recent surgery
Recent accident/injury
Allergies/sensitivities
Fibromyalgia
Pregnancy
Paralysis
Contagious desease
Undiagnosed lump/bump
Cuts/abrasions
Epilepsy
Bell’s palsy, trapped or pinched nerves
Contagious desease, fever, cold, flu
Any condition treated by a medical practitioner
Cancer
Breastfeeding
Please give details about any condition you have checked
Do you have ANY other medical conditions not mentioned above, or anything else about your health we should know?
Have you had symptoms of ANY illness, including a cold, in the last 7 days?
Yes
No
If yes please give more info- it will be at the therapists discretion whether to see you or not
I understand that because this treatment involves maintaining prolonged and close physical contact, there may be elevated risk of disease transmission, including COVID-19, and by signing this form I acknoledge and are aware of the risks involved and give consent to recieve treatment, and understand that this business and therapist cannot be held liable if I experience exposure to any type of contagion
Yes
No
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What kind of pressure do you like?
1
2
3
4
5
Very light
As deep as you can go
1 is Very light, 5 is As deep as you can go
Areas where you feel pain/discomfort/would like extra attention
Are there any areas you'd prefer to avoid?
What is your main goal for the treamtent? I.e relaxation, pain management
Please take the time to read through our privacy policy
Please take the time to read our terms
*
I declare that everything on this form is true, I have declared all medical conditions, and I agree to keep the therapist updated on any changes to my health and accept the therapist has no liability should I fail to do so.
I accept that I, and the therapist have the right to refuse/stop the treatment at any time. Inapropriate behaviour will not be tolerated and will be reported to the local authorities and full payment will be taken.
I understand that at any time I feel pain or discomfort during the session, I will immediatley inform my therapist so they can adjust.
I accept Peace Massage Therapy at Redmayne Lodge has a 24hr cancellation policy and accept I may be charged full payment if I fail to abide.
I give my consent for the treatment to go ahead
Signature
*
Submit
DateTime
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