Consultation Form
Massage
Personal Details
Full Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2026
2025
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Year
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Phone Number
*
-
Area Code
Phone Number
Occupation
*
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Next
Medical History
Briefly describe your general state of health.
*
Are you seeing a health practitioner of any kind? Please state why.
*
Are you currently taking any medication?
*
Yes
No
Please tick any of the conditions that apply to you:
*
Skeletal conditions (arthritis, osteoporosis, rheumatism, kyphosis etc.)
Muscular conditions (aches, fibromyalgia, strains, sprains etc.)
Circulatory conditions (heart conditions, varicose veins, hyper/hypotension, angina etc.)
Respiratory conditions (asthma, hay fever, bronchitis etc.)
Digestive conditions (Crohn's disease, IBS, constipation etc.)
Endocrine conditions (diabetes, hypo/hyperthyroidism etc.)
Neurological conditions (headaches, migraines, epilepsy, MS etc.)
Skin conditions (eczema, psoriasis etc.)
Recent surgeries and past surgeries that still effect you now.
Current injuries and past injuries that still effect you now (broken bones, dislocations, sprains, strains etc.)
None of the above
Please list any medications that you are currently taking.
Please detail any of the conditions identified above and briefly explain how it affects you.
What is your skin type?
Dry
Oily
Normal
Combination
Please list any allergies (or write 'none')
*
Are you pregnant or could you be pregnant?
*
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Lifestyle Questions
Optional Questions
On a scale of 1-10, how would you describe your stress levels?
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
How often are you able to relax
Daily
Weekly
Monthly
Occasionally
Never
What do you do to help you to relax?
On a scale of 1-10, how would you describe your energy levels?
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
How often do you exercise?
Daily
Weekly
Monthly
Occasionally
Never
What do you do for leisure or exercise?
Briefly describe your sleeping patterns.
Anything else that you think I ought to know before the massage?
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Covid-19 Screening
Are you experiencing any of the following symptoms?
*
New cough, sore throat and/or fever
Chills, painful swallowing, muscle/joint ache, loss of taste/smell
Severe breathing difficulties or chest pain
None of the above
Is anyone in your household experiencing Covid-19 symptoms, described above, or recently (in the last 10 days) tested positive for Covid-19?
*
Yes
No
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Client Consent
Please tick the following:
*
Signature
*
Date
*
Submit
Should be Empty: