PAUSE - Client Consultation Form
MASSAGE | AROMATHERAPY | REFLEXOLOGY | HYPNOTHERAPY | MENOPAUSAL WELLBEING
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Email
*
example@example.com
Emergency Contact
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone 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?
*
Yes
No
If you have sensitivities or allergies please advise what they are:
Have you received massage/holistic treatments previously?
*
Please Select
Yes Massage
No Massage
Yes Reflexology
No Reflexology
Yes Aromatherapy
No Aromatherapy
What are your specific concerns at this time? Why are you booking a treatment?
*
What are your stress levels right now?
*
Not stressed at all
Mildly stressed
Moderately stressed
Very stressed
Are you experiencing symptoms of anxiety currently?
*
No
Yes, mild levels
Yes, moderate levels
Yes, high levels
If you are experiencing Anxiety, please rate your level of anxiety between 0-10
What do you consider your skin type?
Normal
Oily
Dry
Sensitive
Other
Please check all that apply.
*
Pregnant
Postpartum (last 6 wks natural or 12 weeks C-section)
Neck Pain
Back Pain
Headaches
Low/High Blood Pressure
Bruise Easily
Diabetes
Depression
Knee/Leg/Hip Pain
Jaw Pain / Clenching/ Grinding
Metal Implants
Fibromyalgia
Epilepsy
Insomnia/Sleep Disturbance
Menopause Symptoms
Menstrual/Gynae Conditions
Surgery within last 6 months
Cancer treatment in last 12 months
What is your desired outcome of receiving therapeutic treatments?
*
Signature
*
Date of Signing
-
Month
-
Day
Year
Date
Submit
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