Massage Consultation Form

Massage Consultation Form
Client Name*
Client Address*
Occupation*
Contact Telephone Number*
Preferably Mobile Telephone
Client Email address*
Sex*

FemaleMale
Age Group*

Under 2020-3030-4040-5050-6060+
Current Activity Levels*

ActiveSedentary
Contraindications (Please tick where appropriate) Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.

PregnancyCardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)HaemophiliaAny condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, CoachMedical oedemaOsteoporosisArthritisNervous/Psychotic conditionsEpilepsyRecent operationsDiabetesAsthmaAny dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)Trapped/Pinched nerve (e.g. sciatica)Inflamed nerveCancerPostural deformitiesDysfunctions of the nervous systems (e.g. cerebral palsy/sroke/ Multiple sclerosisKidney infectionsWhiplashSlipped discUndiagnosed painWhen taking prescribed medicationAcute rheumatism
Contraindications that restrict treatment (Please tick where appropriate)

FeverContagious or infectious diseaseUnder the influence of recreational drugs and/or alcoholDiarrhea or vomitingSkin diseasesUndiagnosed lumps or swellingsLocalised SwellingInflammationVaricose veinsPregnancy (abdomen)CutsBruisesAbraisonsScar tissues (2 years for major operation and 6 months for a small scar)SunburnHormonal implantsAbdomen (first few days of menstruation depending how the client feels)HaematomaHemiaRecent fractures (minimum 3 months)Cervical spondylitisGastric ulcersAfter a heavy meal
Written permission required by GP/Specialist (Separate form to be collected)

YesNo
Personal Information

Please tick or answer where appropriate
Muscular/skeletal problems

BackAches/painsStiff jointsHeadaches
Digestive Problems

ConstipationBloatingLiver/Gall bladderStomach
Circulation

HeartBlood pressureFluid retentionTired LegsVaricose VeinsCelluliteKidney problemsCold hands and feet
Gynaecological

Irregular periodsPMTMenopauseHRTPillCoil
Nervous System

MigraineTensionStressDepression
Immune System

Prone to infectionsSore throatsColdsChestSinuses
List any Antibiotics/Medication taken
List any Herbal remedies taken
Ability to relax

GoodModeratePoor
Sleep quality

GoodPoor
Average hours sleep per night
Do you see natural daylight in your workplace?

YesNo
How many hours a day do you work at a computer?
Do you eat regular meals

YesNo
Do you eat in a hurry?

YesNoSometimes
Do you suffer from any of the following

Food allergiesOver eatingBulimiaAnorexiaOther
Please list any food allergies
Do you exercise? If so how many times per week?
What is your skin type

DryOilyCombinationSensitiveDehydrated
Do you suffer or have you suffered from

DermatitisAcneEczemaPsoriasisAllergiesHay FeverAsthmaSkin Cancer
Stress levels at home (10 being highest)
Stress levels at work (10 being highest)
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

Clear
Date

DayMonthYear
Date

Massage Consultation Form

Personal Information

Sport Details

Disclaimer Form

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