Massage Consultation Form
The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
Postcode
Phone number
*
E-mail
*
example@example.com
Occupation
*
Emergency Contact Name & Mobile
Sex
*
Female
Male
Have you recently had any operation/surgery ?
*
Yes
No
If yes, details of treatment:
Are you currently attending a GP/complimentary therapist for any condition/treatment?
*
Yes
No
If yes, details of condition / treatment
Current Medication (incl vitamins):
*
How did you hear about me?
*
Website / Online Search
Instagram
Facebook
Referral
Other
If Referral, please list name
If Other, please let me know where
What is the objective of your visit (eg: relaxation, specific condition / pain)?
*
Your General Health
Have you experienced any of these health conditions in the past or present?
*
Arthritis
Auto-Immune Disorders
Asthma
Back Complaints
Blood Pressure
Bruising/scar tissue
Cancer
Covid-19
Diabetes
Digestive problems
Depression/Anxiety
Dysfunction of the nervous system (Parkinson's, Sclerosis multiplex, Motor neuron disease, ME)
Epilepsy / Seizure Disorder
Fever
Frequent Cold Sores
HIV/AIDS
Hepatitis
Headaches / Migraines
Heart problem
Hormone Imbalance (HRT/ irregular cycle)
Insomnia
Infectious disease
Osteoporosis
Recurring infections
Recent fracture/sprain
Sinusitis
Skin conditions
Swelling/oedema
Tinnitus
Thrombosis/varicose veins
Vertigo
Other
None
If you checked yes to any of these please provide further information. If not mark N/A
Your Lifestyle
Stress Levels at Home
*
High
Medium
Low
Stress Levels at Work
*
High
Medium
Low
Energy level
*
High
Medium
Low
Sleep quality
*
Poor
Moderate
Good
How many hours do you work on computer?
Do you exercise regularly?
*
Yes*
No
*If Yes, please give details:
What do you do for relaxation?
Any known allergies (eg: aspirin, latex, nuts, essential oils)?
*
Yes*
No
*If Yes, please give details:
FEMALE CLIENTS ONLY: Are you / could you be pregnant
*
Yes
No
Are you breastfeeding?
*
Yes
No
N/A
Do you smoke?
*
Yes
No
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
*
Yes
No
Do you drink alcohol
*
Yes
No
What is your daily water intake (glasses / litres)
*
Are there any other information you would like to make your therapist aware of? If yes, please give details:
Reservation & Cancellation Policy for all current and future appointments: I understand that unanticipated events happen occasionally in everyone’s life. In order to be effective and fair to all clients, the following policies are honoured: 24 hour advance notice is required when cancelling or rescheduling an appointment. This allows the opportunity for someone else to book in. If you are unable to give 24 hours advance notice a cancellation fee equal to the reserved service booking fee will incur. No Shows will be charged 100%.
*
I understand the reservation and cancellation policies at Harmony Wellbeing
CLIENT DECLARATION: I declare that the information I have given is correct and as far as I am aware I can undertake a treatment without any adverse effects. I understand that withholding information or providing misinformation may result in contraindications and I am willing to proceed. I understand that complementary therapies do not substitute medical treatment. If I experience any discomfort during the treatment I will inform the therapist immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof. I understand that my therapist may require me to obtain permission from my doctor before my appointment.
*
By checking this box I understand and accept this statement
I, Anett Nagyapati by Harmony Wellbeing will occasionally contact clients to follow up on a session. I also send booking confirmation and a reminder via SMS. I occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for Harmony Wellbeing to:
*
Contact you about appointment and relevant follow up.
Send occasional emails with news, special offers etc.
Signature
*
Thank you for taking the time to complete this form - I look forward to seeing you soon.
Anett
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