Client consultation form - Holistic Massage

  • Client Consultation Form - Massage

    Please fill out this form at your convenience before your appointment with Nathan.
  • Date of your appointment*
     / /
  • Date of last visit to the doctor*
     - -

  • Client Profile

  • Medical Contra-indications

  • Are you pregnant?*
  • How many weeks?*

  • Massage cannot be given between 0-12 weeks due to risk of miscarriage

    Please contact Nathan for more info
  • Please select all that apply to you*

  • Contra-indication Restrictions

  • Please select all that you are experiencing*
  • Do you have any allergies?*

  • Consent

    If you selected any of the conditions above, please read the information and sign below to give your informed consent to receive Massage. Please read carefully and only sign if you are in full agreement with its contents.

  • I [your name below] confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed without confirmation from my own GP or Consultant for my selected conditions above.I hereby indemnify the therapist Nathan Krifdom (Buddha Hand Holistics) against any adverse reaction sustained as a result of the treatment.I understand that it is my responsibility and not that of the therapist to consult with my doctor regarding suitability of receiving this treatment, if I so wish to.
  • Today's date
     - -

  • Medical History

    Please select all that apply
  • Muscular/skeletal problems*
  • Digestive problems*
  • Circulation*
  • Gynaecological*
  • Nervous system*
  • Respiratory*
  • Skin conditions*
  • Skin type*
  • Immune system - select which you are prone to*

  • Lifestyle

    Please select all that apply
  • In general, how is your ability to relax?*
  • What is your sleep pattern*
  • How would you rate your sleep?*
  • Do you have natural daylight while at work or the place you spend most of your day?*
  • Do you work at a computer?*
  • Do you smoke/vape?*
  • Do you drink alcohol?*
  • Do you exercise?*

  • Diet

  • Which meals do you eat regularly?*
  • Do you normally eat in a hurry?*
  • Do you take any food/vitamin supplements?*

  • _________

    How many portions of each of these items does your diet contain per day?

  • How many food items per day on average contain:

  • _________

    How many units of these drinks do you consume per day?

  • YOU'RE DONE!

    Thank you so much for taking the time to fill out this form. See you at your appointment!
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