MOBILE MASSAGE - BODY MASSAGE CONSULATION FORM

Becky's Mobile Massage Therapy.

Name

Address.

Street Address

Street Address Line 2

CityCounty

Postcode

Email Address.

example@example.com

Contact Number.

Emergency Contact Name/Number.

Occupation.

Height.

Weight.

GP and Practice Address.

Date of Birth.

General State of Health.

Are you taking any medication. If yes please state which ones, and for what medical purpose you are taking them.

Are you following a special Diet.

How would you decribe your stress levels LOW/MED/HIGH

How would you describe your energy levels LOW/MED/HIGH

Do you exercise regularly Y/N

How would you describe your sleep pattern.

Could you be pregnant Y/N

Are you breastfeeding. Y/N

Date of last period.

What do you do for relaxation.

Have you had a massage before. If so what was the reason for the treatment. Y/N

Do you suffer with blood pressure? High or Low Y/N

Do you suffer with unstable blood pressure? Y/N

Do you suffer with any nut allergies? Y/N

Do you have any recent scar tissue? Y/N

Do you suffer with any heart disorders? Y/N

Have you recently had a hemorrhage? Y/N

Do you have a history of thrombosis embolism/Deep vein thrombosis. Blood clot forming in lower leg, thigh, pelvis or arm? Y/N

Do you have varicose veins? Y/N

Do you have a dysfunction of the nervous system? Y/N

Do you suffer from any swelling/oedema? Y/N

Do you suffer from any infectious diseases? Y/N

Do you suffer with any skin disorders, infectious or not? Y/N

Have you recently had any operations? Y/N

Have you recently had any inoculations/jabs? Y/N

Do you have any severe bruising? Y/N

Have you had/do you have cancer? Y/N

Are you currently suffering with a high fever? Y/N

Do you have any recent fractures or sprains? Y/N

Do you have diabetes? Y/N

Do you suffer from any allergies? Y/N

Do you have osteoporosis? Y/N

Have you consumed alcohol within 12 hours prior to the massage? Y/N

Do you suffer from arthritis? Y/N

Have you consumed a heavy meal 1 hour prior to the massage? Y/N

Do you suffer from any back problems? Y/N

Do you have sensitive skin? Does your skin react easily to trying new/products? Y/N

Do you have epilepsy? Y/N

Do you have any recent cuts or abrasions? Y/N

Do you suffer with any mental health problems? Y/N (e.g Depression, Anxiety etc.) If Yes please say which.

Do you currently have any signs of a cold/flu or covid? Y/N

Please Note: Do you have any other medical issues or symptoms which haven't been mentioned already? If yes, please can you write them down below.

Client Declaration - (Please read.)

I declare the information that I have given is true and correct and that as far as I'm aware, I can undertake treatment with this massage therapist without any adverse effects. I have been fully informed about contra-indications and I am willing therefore to proceed. I understand that body massage is not a substitute to medical advice and/or treatment.
I agree under GDPR -(General Data Proctection Regulation). This therapist has a right to delete, edit and store your consultation information in a safe and secure place within her business. And she will only share clients info if she would need to consult the client's GP herself, with the client's consent.
Once you have filled the form out, I shall be notifed and once I have gone over your form. I will then be touch with you to arrange a phone call to discuss a few things further.
Many Thanks.
Becky

Client signature.

Date*

Date

CONSULTATION FORM.

Personal Details.

Conditions and/or symptoms.