Client Consultation Form - Massage
Please fill out this form at your convenience before your appointment with Nathan.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
Town/City
County
Postal Code
Profession
*
Mobile number
*
Home phone
Date of your appointment
Date of your appointment
*
/
Day
/
Month
Year
Date
Time of your appointment
Hour Minutes
AM
PM
AM/PM Option
Age
*
Gender
*
GP Surgery Address
*
Practice Name
Street Address
Town/City
County
Postal Code
Date of last visit to doctor
Date of last visit to the doctor
*
-
Day
-
Month
Year
Date
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Client Profile
Medical Contra-indications
Are you pregnant?
*
Yes
No
How many weeks?
*
0-12
2nd trimester
3rd trimester
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
*
Currently being treated by a GP or another complimentary practitioner for any condition
Taking prescribed medication
Undertaken a recent operation
Have a hormone implant
Any dysfunction of the nervous system e.g. multiple sclerosis, Parkinson's disease, motor neurone disease?
Any skeletal/muscular conditions e.g. cervical spondylitis, osteoporosis, arthritis, whiplash, slipped disk?
Any conditions causing muscular spasticity e.g. cerebral palsy?
Any cardiovascular conditions e.g. thrombosis, phlebitis, hypertension, hypotension, heart conditions?
Any mental / psychotic conditions?
Any undiagnosed pain?
Asthma
Diabetes
Epilepsy
Kidney infection
Cancer
Haemophilia
Bell's palsy
Medical oedema
Trapped/pinched nerve e.g. sciatica
Inflamed nerve
Rheumatoid arthritis
None
Contra-indication Restrictions
Please select all that you are experiencing
*
Fever
Contagious or infectious disease
Diarrhoea and vomiting
Undiagnosed lumps and bumps
Cuts / Bruises / Abrasions
Sunburn
Hypersensitive skin
Scar tissue (area will be avoided - 2 years for major operation; 6 months for a small scar)
Localised swelling
Varicose veins (area will be avoided)
Skin diseases
Hernia
Gastric ulcers
Haematoma
Inflammation
Recent fractures (minimum 3 months)
Menstruation (abdomen avoided first few days after)
None
Do you have any allergies?
*
Yes
No
If you selected any of the conditions above, please give details for each conditions e.g. how long you have had it and how it affects you.
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.
Name
First Name
Last Name
Today's date
Today's date
-
Month
-
Day
Year
Date
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Medical History
Please select all that apply
Why would you like Massage?
*
Are there any parts of your body you do not wish to be massaged/touched? E.g. feet, face (private areas are avoided)
Muscular/skeletal problems
*
Back
Aches/pains
Stiff joints
Headaches
None
Digestive problems
*
Constipation
Bloating
Liver/gall bladder
Stomach
None
Circulation
*
Heart condition
Blood pressure issues
Fluid retention
Tired legs
Varicose veins
Cellulite
Kidney problems
Cold hands and feet
None
Gynaecological
*
Irregular periods
P.M.T.
Menopause
H.R.T.
Pill
Coil
None
Nervous system
*
Migraine
Tension
Stress
Depression
None
Respiratory
*
Allergies
Hay fever
Asthma
None
Skin conditions
*
Dermatitis
Acne
Eczema
Psoriasis
Skin cancer
None
Skin type
*
Dry
Oily
Combination
Sensitive
Dehydrated
Immune system - select which you are prone to
*
Infections
Colds
Sore throats
Chest issues
Sinus issues
None
Are you taking any medication? If so, please give details.
Are you taking any herbal remedies? If so, please give details.
Any other health conditions or things your therapist should know?
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Lifestyle
Please select all that apply
How many children do you have? (If none put 0)
*
In general, how is your ability to relax?
*
Good
Moderate
Poor
What methods do you use to relax?
*
What is your sleep pattern
*
Regular
Mixed
Irregular
How would you rate your sleep?
*
Good
Moderate
Poor
On average, how many hours of sleep a night?
*
Do you have natural daylight while at work or the place you spend most of your day?
*
Yes
No
It changes
What is your work environment?
*
Do you work at a computer?
*
Yes
No
Occasionally
If yes/occasionally, how many hours at a time on average?
Do you smoke/vape?
*
Yes
No
Used to but quit
If yes, how often?
Do you drink alcohol?
*
Yes
No
If yes, how many units per week?
Do you exercise?
*
No
Occasionally
Irregularly
Regularly
What type/s of exercise do you do?
Stress level at work
*
Please Select
1 (no stress)
2
3
4
5
6
7
8
9
10 (heavily stressed)
Stress level at home
*
Please Select
1 (no stress)
2
3
4
5
6
7
8
9
10 (heavily stressed)
Reasons for stress?
Diet
Which meals do you eat regularly?
*
Breakfast
Lunch
Dinner
Do you normally eat in a hurry?
*
Yes
No
It depends
Do you take any food/vitamin supplements?
*
Yes
No
If yes, what do you take?
_________
How many portions of each of these items does your diet contain per day?
Fresh fruit
*
Fresh vegetables
*
Protein
*
Dairy products
*
Sweet things
*
How many food items per day on average contain:
Added salt
*
Added sugar
*
What are your protein sources?
*
_________
How many units of these drinks do you consume per day?
Tea
*
Coffee
*
Fruit juice
*
Water
*
Soft drinks
*
Other, please give details
Do you suffer from food allergies? Please give details
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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