Oncology Massage Consultation Form

Massage Consultation Form

In order for me to carry out the safest and most beneficial treatment for you, it is necessary to ask the following questions. Please complete this form prior to attending the studio, ideally at least 48hrs prior to your first appointment or as soon as possible after booking.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email*
example@example.com
Phone Number*

Area CodePhone Number
Your age range

Under 2020-3030-4040-5050-6060+
Name of GP/surgery (please include address and telephone number)*
Have you had massage therapy before? If yes, was there anything you did or didn't like?
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION * In circumstances where medical permission cannot be obtained, clients will be required to give informed consent prior to treatment by signing this form:

Cardiovascular conditions (thrombosis, phlebitis, hyper/hypotension, heart conditions)Recent operations (cancer and non-cancer related)Postural deformitiesHaemophiliaDiabetesConditions causing muscular spasticity e.g., cerebral palsyAny medical condition already being treated by a GP or other medical practitionerAsthmaWhiplash/slipped disc/trapped or inflamed nerve/sciaticaMedical oedemaNervous system dysfunction e.g., multiple sclerosis, parkinson's disease, MNDArthritisMental health conditions e.g., psychosis, bipolar, schizophreniaAcute rheumatismEpilepsyCervical spondylitis
Please list any medications, supplements, or herbal remedies you currently take (please be aware that some medications may require prior medical consent)
CONTRAINDICATIONS WHICH MAY RESTRICT MASSAGE TREATMENT:

FeverCuts/bruises/abrasionsContagious or infectious diseasesSkin diseases/disordersHaemetomaHerniaPregnancyMenstruation (within first few days of period at the time of appointment)Diarrhoea and/or vomitingScar tissue (within 2 years for major operations or 6 months for small scars)Recent fractures (minimum 3 months)Varicose veinsGastric ulcersUndiagnosed pain/lumps/bumps/lesionsLocalised swellingHormonal implantsInflammationConditions affecting the neckDigestive problems e.g., constipation, bloating, liver/gall bladder issuesCirculation problems e..g., blood pressure, heart palpitations, cold hands/feet, fluid retentionHeadaches/migrainesImmune system disorders e.g., prone to infection, sinus issues, autoimmune conditionsMetal implantsFibromyalgiaAnxiety/depression/low moodPerimenopause/menopauseSleep problems or sleep disordersHRT
Please list allergies or sensitivities:*
Please list any recent injuries not already highlighted:*
GENERAL HEALTH & LIFESTYLE INFORMATION (the following questions are optional)
Do you exercise? If so, please state which activities and how many times per week.
Approximately how many hours of sleep do you get per night?
What prompted you to book your massage appointment e.g., muscle tension/aches and pains, needed a relaxing treat, have experienced a stressful life event or something else (please state)?
What is your stress level right now?

LowAverageSomewhat StressedVery Stressed
DISCLAIMER:

To the best of my knowledge I confirm that the information I have provided is true and I have not withheld any information concerning my health and wellbeing. I will keep my massage therapist updated on my health should there be any changes to the answers given in this form.

Where relevant, I agree to provide written permission from my GP or other primary care provider in advance of any massage treatment should this be requested/required.

I understand that my massage therapist does not diagnose illness, disease or any other physical or mental condition. I understand that the treatment I receive at Sekhem Massage Therapy is not a substitute for medical examination, advice, diagnosis or treatment.
Signature*

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