PAUSE - Client Consultation Form

PAUSE - Client Consultation Form

MASSAGE | AROMATHERAPY | REFLEXOLOGY | HYPNOTHERAPY | MENOPAUSAL WELLBEING
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Occupation
Email*
example@example.com
Emergency Contact

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
How did you hear about Pause?
List any medications, supplements, or herbal remedies you currently take:
Please list injuries or surgeries:*
Do you have any sensitivities or allergies?*

YesNo
If you have sensitivities or allergies please advise what they are:
Have you received massage/holistic treatments previously?*
What are your specific concerns at this time? Why are you booking a treatment?*
What are your stress levels right now?*

Not stressed at allMildly stressedModerately stressedVery stressed
Are you experiencing symptoms of anxiety currently?*

NoYes, mild levelsYes, moderate levelsYes, high levels
If you are experiencing Anxiety, please rate your level of anxiety between 0-10
What do you consider your skin type?

NormalOilyDrySensitiveOther
Please check all that apply.*

PregnantPostpartum (last 6 wks natural or 12 weeks C-section)Neck PainBack PainHeadachesLow/High Blood PressureBruise EasilyDiabetesDepressionKnee/Leg/Hip PainJaw Pain / Clenching/ GrindingMetal ImplantsFibromyalgiaEpilepsyInsomnia/Sleep DisturbanceMenopause SymptomsMenstrual/Gynae ConditionsSurgery within last 6 monthsCancer treatment in last 12 months
What is your desired outcome of receiving therapeutic treatments?*
Signature*

Clear
Date of Signing

MonthDayYear
Date
Should be Empty: