Client Intake Form for Attitude Wellbeing

Client Consultation Form

For Massage / Reflexology / Foot Gait Analysis / Reiki / Lymphatic Massage / Cold Water Therapy / Red Light Therapy
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

PostcodeCountry
Email*
example@example.com
Mobile Number*
Date of Birth*

DayMonthYear
Sex*

MaleFemaleOther
Occupation*
Doctor's Details*
In case of Emergency*

First NameLast Name
In Case of Emergency's Phone Number*
Health Questions

Please fill in as accurately as you can, as some conditions are not suited to some forms of massage.
Have you or a member of your household experienced any Covid19 symptoms within the last month?

NoOther
Have you had surgery in the last 6 months?*

YesNo
Do you have Diabetes?*

YesNo
Do you suffer from arthritis?*

YesNo
Is your blood pressure either high or low?*

Yes - HighYes - LowNeither
Are you taking bloodpressure medication?*

YesNo
Have you ever had a DVT (Deep Vein Thrombosis) or Pulmonary Embollism (PE)?*

Yes - DVTYes - PENo
Do you have varicose veins?*

YesNo
Do you have cardiac or circulatory problems?*

YesNo
Do you suffer from Asthma?*

YesNo
Do you suffer from Epilepsy?*

YesNo
Do you suffer from joint swelling?*

NoOther
Do you experience frequent headaches?*

YesNo
Do you suffer from Migraines? If Yes, when was your last one?*

NoOther
Do you have raised cholesterol?*

YesNo
Do you have a heart condition?*

YesNo
Do you have osteoporosis?*

YesNo
Do you have any Allergies?*

NoOther
Do you suffer from any Abdominal issues?*

NoOther
Do you bruise easily?*

YesNo
Do you suffer from back pain?*

NoOther
Any broken bones in the past two years?*

NoOther
Any injuries in the past two years?*

NoOther
Do you have numbness or stabbing pains?*

NoOther
Are you sensitive to touch or pressure in any area?*

NoOther
Do you regularly suffer from Stress?*

YesNo
Are you, or is there any possibility that you might be pregnant?*

YesNo
Have you ever had surgery?*

NoOther
Are you on any medication?
Please list medication taken and why you take it?
Is there any other medical information that you feel you should provide?
If you answered YES to any of the questions above, have you sought medical advice and your GP has agreed that you may receive treatment?*

YesNoAnswered No to all above questions
How did you find out about Attitude Wellbeing?
Signature*

Clear
Please sign with mouse or finger (if touch screen)
Todays date*

DayMonthYear
Newsletter

I am happy to receive your newsletter containing offers and updates
Should be Empty:

Client Consultation Form

Health Questions