Massage Consultation Form
Client Name
*
Client Address
*
Occupation
*
Contact Telephone Number
*
Preferably Mobile Telephone
Client Email address
*
Sex
*
Female
Male
Age Group
*
Under 20
20-30
30-40
40-50
50-60
60+
Current Activity Levels
*
Active
Sedentary
Contraindications (Please tick where appropriate) Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.
Pregnancy
Cardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)
Haemophilia
Any condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, Coach
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Asthma
Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)
Trapped/Pinched nerve (e.g. sciatica)
Inflamed nerve
Cancer
Postural deformities
Dysfunctions of the nervous systems (e.g. cerebral palsy/sroke/ Multiple sclerosis
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
Contraindications that restrict treatment (Please tick where appropriate)
Fever
Contagious or infectious disease
Under the influence of recreational drugs and/or alcohol
Diarrhea or vomiting
Skin diseases
Undiagnosed lumps or swellings
Localised Swelling
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abraisons
Scar tissues (2 years for major operation and 6 months for a small scar)
Sunburn
Hormonal implants
Abdomen (first few days of menstruation depending how the client feels)
Haematoma
Hemia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
After a heavy meal
Written permission required by GP/Specialist (Separate form to be collected)
Yes
No
Personal Information
Please tick or answer where appropriate
Muscular/skeletal problems
Back
Aches/pains
Stiff joints
Headaches
Digestive Problems
Constipation
Bloating
Liver/Gall bladder
Stomach
Circulation
Heart
Blood pressure
Fluid retention
Tired Legs
Varicose Veins
Cellulite
Kidney problems
Cold hands and feet
Gynaecological
Irregular periods
PMT
Menopause
HRT
Pill
Coil
Nervous System
Migraine
Tension
Stress
Depression
Immune System
Prone to infections
Sore throats
Colds
Chest
Sinuses
List any Antibiotics/Medication taken
List any Herbal remedies taken
Ability to relax
Good
Moderate
Poor
Sleep quality
Good
Poor
Average hours sleep per night
Do you see natural daylight in your workplace?
Yes
No
How many hours a day do you work at a computer?
Do you eat regular meals
Yes
No
Do you eat in a hurry?
Yes
No
Sometimes
Do you suffer from any of the following
Food allergies
Over eating
Bulimia
Anorexia
Other
Please list any food allergies
Do you exercise? If so how many times per week?
What is your skin type
Dry
Oily
Combination
Sensitive
Dehydrated
Do you suffer or have you suffered from
Dermatitis
Acne
Eczema
Psoriasis
Allergies
Hay Fever
Asthma
Skin Cancer
Stress levels at home (10 being highest)
1
2
3
4
5
6
7
8
9
10
Stress levels at work (10 being highest)
1
2
3
4
5
6
7
8
9
10
Sport Details
What is your main sport/activity
How often do you play/train per week
Please list any injuries sustained whilst participating in your sport or activity
Disclaimer Form
Please read the following and tick the appropriate box, by ticking the box you are confirming you are in full agreement with the statements contents.
Client Information
*
I confirm that I have understood the treatment that I am going to receive. I also confirm that I am willing to proceed without confirmation from my own G.P or Consultant.
I confirm that I have understood the treatment and given my medical history I would prefer to consult with my GP or Consultant prior to receiving the treatment.
Client Full Name
*
Signature
Date
-
Day
-
Month
Year
Date
Vissza
Következő
Save
Heading
Save
Submit
Should be Empty: