Massage Consultation Form

Massage Consultation Form

Deep Tissue and Sports Therapy
Personal Information
Client Name

PrefixFirst NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number
Please enter a valid phone number.Format: 00000000000.
Home Number
Please enter a valid phone number.Format: 00000-000-000.
Email
example@example.com
Address

Street Address

Street Address Line 2

Town/CityCounty

Post Code
Gender
Occupation
Age Group
Emergency Contact Information

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: 00000000000.

Lifestyle

Please tick or answer where appropriate
Current Activity Levels
Sleep quality
Average hours sleep per night
Is your job sedentary?
Stress levels at home (10 being highest)
Stress levels at work (10 being highest)
What activities/sports/exercises do you participate in?
What is your main sport/activity?
Please include the level you play at if relevant.

Present Complaint

Please tick or answer where appropriate
What is your reason for seeking massage therapy?
Have you had a type of massage before?
What type of massage are you seeking?
What pressure do you THINK you prefer?
Are there any areas you DON'T want treated?
Please give details - (i.e. feet, abdomen, armpits) and why (i.e. ticklish, sensitive).
What are your goals for this treatment session?
Please feel free to include short and long term goals.

Marketing
How did you hear about me?

Other

Consent 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.
M.Strads Massage Therapy is required to retain any information for the purpose of consultation, recording of treatments, and if necessary, for use of third party medical practitioners (i.e. at the request of a patient in consultation with a GP.) If you would like more information, please ask.
I hereby give consent to record personal data:
Massage involves the manipulation fo soft tissues, through the hands, or instruments. There are many benefits to massage, however, there is a small risk of bruising, skin irritation, and discomfort post treatment. Massage oils and creams will be used in the treatment. Pleaee make sure you disclose any allergies/sensitivities in the form.

The information I have given is correct and to the best of my knowledge and should any changes occur, I will update the business.
Treatment Consent
Client Consent
Client Full Name
Signature
Signature
Date

DayMonthYear
Date
Parental Consent (Where Applicable)

To be completed by Parent or Guardian if client is under the age of 18.
By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) and consenting to the treatment recommended by the therapist. You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.You also agree that you have completed the Consultation Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).
Parent/Guardians Full Name
Signature
Signature
Date

DayMonthYear
Date
Should be Empty:

Massage Consultation Form

Personal Information

Medical History

Lifestyle

Present Complaint

Marketing

Consent Form

Parental Consent (Where Applicable)