Massage Therapy Consultation Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
County
Postcode
Emergency contact
Name
Number
Health Data
Do you have any allergies or sensitivities?
If yes, please specify in the field above. Includes nuts, oils and skin products.
Are you pregnant or nursing?
If yes, please specify how many weeks and any high risk factors in the field above.
Have you had any joint replacement surgery, injuries or medical procedures in the last two years?
If yes, please specify in the field above.
Do you have any current injuries or areas of discomfort/pain?
If yes, please specify in the field above.
Are you taking any regular medication?
If yes, please specify in the field above.
Do you have any of the following conditions?
Arthritis
Cancer
Fibromyalgia
Heart condtions
Neurological disorder
Osteoporosis
High/low Blood pressure
Diabetes
Neuropathy/numbness
Previous Stroke
Varicose veins
Bursitis
Bleeding/clotting disoredr
Other
Please provide more information if you have marked any of the above conditions.
Massage Information
What is your reason for seeking massage?
Relaxation
Injury
Stress release
Other
What pressure would you prefer?
Light
Medium
Firm
Are there any areas you prefer not to be massaged?
e.g. neck, feet, abdomen
Disclaimer
*
I authorise the use of massage oils, wax and liquid wax to my body.
I understand that massage therapy is not a substitute for medical treatment.
I will inform my therapist of any changes to my health or medical conditions.
I acknowledge that all information I provided in this form is true and accurate.
Signature
Date Signed
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
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