Indian Head Mobile Massage - Consultation Form.

Personal Details.

Name.

Address

Postcode

Phone number

Area CodePhone Number

Date of birth.

Occupation

GP name

GP practice address

General State of Health.

Do you wear contact lenses or glasses? Y/N

Do you exercise regularly? Y/N

Are you taking any medication? Y/N

Are you on any special diet? Y/N

Do you drink alcohol? Units per week. Y/N

How would you describe your stress levels? High, medium or low.

How would you describe your energy levels? High, medium or low.

How would you describe your sleep pattern?

What do you do for relaxation?

Have you ever had an Indian Head Massage treatment before? Y/N

Reason for treatment?

Conditions and/or symptoms.

Do you suffer from any of the following conditions:

Anxiety/stress? Y/N

Depression/Low mood? Y/N

Sleeping problems? Y/N

Headaches/migraines? Y/N

Neck/shoulder strain? Y/N

Eye strain? Y/N

Tinnitus? Y/N

TMJ disorder ( Temporomandibular Joint Disorder) Y/N

Do you suffer with acute (resolves within 2-3 weeks) or chronic (lasting longer than 3 months ) sinusitis? ( e.g nasal / facial congestion and nasal pain/pressure? If anwser Yes, please state which symptoms you currently have, or have had in the past. Y/N

Do you suffer with allergic sinusitis, (caused by allergies, nasal stuffiness, runny nose, sneezing or watery eyes.

Premature greying? Y/N

Dandruff? Y/N

Hair loss? Y/N

Psoriasis/eczema? Y/N

Do you have any cysts or lumps? Y/N

Do you suffer from unstable blood pressure? Y/N

Do you suffer from any heart disorders? Y/N

Do you have epilepsy? Y/N

Do you have diabetes? Y/N

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

Are you suffering from any infectious diseases or disorders? Y/N

Do you have or have you recently had a heavy cold, fever or Covid? Y/N

Have you suffered any recent head or neck injuries? Y/N

Have you had a recent operation or have scar tissue to be aware of? Y/N

So you suffer from any skin disorders? Y/N

Do you have any severe bruising? Y/N

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

Have you recently had any operations? Y/N

Do you suffer from any allergies? Y/N

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

Do you have any other medical or mental health conditions?

Please give details if you answered yes to any of the previous questions. And if you have any other condition/symptom that are not listed above, please add them here.

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.

Client Signature

Becky's Mobile Massage Therapy.

Indian Head - Consultation Form.